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Digitized  by  tine  Internet  Archive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/medicaldiagnosisOOdaco 


MEDICAL    DIAGNOSIS 


WITH 


SPECIAL  REFERENCE  TO  PRACTICAL  MEDICINE. 


GUIDE  TO  THE  KNOWLEDGE  AND  DISCRIMINA- 
TION OF  DISEASES. 


BY 

J.   M.   DA   COSTA,  M.D.,  LL.D., 

PROFESSOR   OF    PRACTICE   OF   MEDICINE   AND   OF   CLINICAL   MEDICINE   AT   THE   JEFFERSON 

MEDICAL  COLLEGE,  PHILADELPHIA;  PHYSICIAN  TO  THE  PENNSYLVANIA  HOSPITAL; 

CONSULTING    PHYSICIAN   TO   THE   CHILDREN'S   HOSPITAL,  ETC.,  ETC. 


^[[ttstratcd  tuitli  SEnsratjittss  xtn  ^oo5> 


SEVENTH   EDITION,  REVISED. 


PHIIiADELPHIA: 

J.   B.   LIPPINCOTT    COMPANY. 

LONDON:    10  HENRIETTA   STREET,  CO  VENT   GARDEN. 
1890. 


Entered,  according  to  Act  of  Congress,  in  the  year  1890,  by 

J.  M.  DA  COSTA,  M.D., 
In  the  Office  of  the  Librarian  of  Congress  at  Washington. 


I  O/    ,'/  " 


EXTRACT  FROM  PREFACE  TO  THE  FIRST  EDITION. 


My  chief  aim  in  writing  this  work  has  been  to  furnish  ad- 
vanced students  and  yonng  graduates  of  medicine  with  a  guide 
that  miffht  be  of  service  to  them  in  their  endeavors  to  discrimi- 
nate  disease.  I  have  sought  to  oifer  to  those  members  of  the 
profession  who  are  about  to  enter  on  its  practical  duties  a  book 
on  Diagnosis  of  an  essentially  practical  character, — one  neither 
so  meagre  in  detail  as  to  be  next  to  useless  when  they  encounter 
the  manifold  and  varying  features  of  disease,  nor  so  overladen 
with  unnecessary  detail  as  to  be  unwieldy  and  lacking  in  precise 
and  readily-applicable  knowledge. 

In  executing  my  undertaking,  two  plans  offered  themselves: 
either  to  describe  morbid  states  in  comjDliance  with  the  usual 
pathological  classification  followed  in  treatises  on  the  Practice  of 
Medicine,  or  to  group  them  according  to  their  marked  symptoms. 
The  former  plan  would  have  been  far  the  easier,  but  the  latter 
seemed  to  me  the  more  suitable  for  a  volume  of  this  kind  ;  and, 
although  it  has  involved  much  labor,  and  lias  rendered  the  task 
much  more  difficult  of  accomplishment,  its  advantages  appeared 
to  me  so  great  that  I  have  adopted  it  throughout.  That  this 
attempt  at  a  purely  clinical  classification  is  not  perfect,  I  am  fully 
aware.  But,  with  all  its  shortcomings,  I  venture  to  hope  that  it 
will  not  be  devoid  of  value. 

Some  of  the  statements  made  may  appear  too  absolute,  and 
as  not  taking  sufficient  notice  of  the  many  exceptions  which  may 
arise.  But  it  was  impossible  to  avoid  this  without  very  lengthy 
discussion  :  and  even  in  the  lengthiest  discussion  all  exceptions 
and  all  possible  points  of  fallacy  would  not  have  been  mentioned ; 
for  Nature  does  not  limit  herself  in  her  irregularities  any  more 
than  in  her  rules.  The  text  must,  therefore,  be  looked  upon  as 
treating  only  of  general  laws  and  of  their  most  notable  infrac- 
tions •  in  fact,  but  as  a  series  of  etchings,  with  here  and  there  a 
prominent  figure  shaded,  but  not  as  an  attempt  to  reproduce  the 

3 


4  EXTRACT    FROM    PREFACE   TO    THE    FIRST    EDITION. 

coloi's  of  an  original  wliose  varied  lines  could  not  be  closely  copied, 
even  by  the  hand  of  a  master. 

The  main  object  of  this  work  is,  what  its  title  implies,  the 
consideration  of  ^Medical  Diagnosis.  In  connection  with  this, 
I  have  endeavored  to  take  cognizance  of  the  prognosis  of  indi- 
vidual affections,  and  occasionally  the  record  of  cases  has  been 
introduced  by  way  of  elucidation.  To  have  done  this  to  a  much 
greater  extent,  though  in  some  respects  desirable,  would  have 
swelled  the  work  to  an  inordinate  size. 

The  wood-cuts  employed  as  illustrations  are  all  original.  Many 
are  from  sketches,  or  at  least  are  based  on  sketches,  taken  directly 
from  cases  of  interest. 

Philabelphia,  April,  18G4. 


PREFACE  TO  THE  SEVENTH  EDITION. 


This  edition  has  been  throughout  revised,  and  much  new  mat- 
tei'  has  been  incorporated.  But,  by  rearranging  and  condensing 
some  chapters,  the  work  has  not  been  materially  increased  in  size. 
A  number  of  wood-cuts  have  been  added,  in  illustration  especially 
of  such  micro-organisms  as  have  been  proved  to  be  of  practical 
significance  in  diagnosis.  The  new  drawings  were  mostly  made 
from  nature  by  Dr.  Coplin  and  Dr.  Joseph  Leidy,  Jr.  I  must 
also  express  my  indebtedness  to  Dr.  Gould,  Dr.  Hershey,  and  Dr. 
Ijcifmann  for  aid  in  preparing  the  volume  for  the  press.  It  is  a 
pleasure  to  be  able  to  record  that  a  second  edition  of  the  German 
translation  by  Dr.  Engel  and  Dr.  Posner  lias  appeared  in  Berlin  ; 
that  a  Russian  translation  has  been  issued  ;  and  that  a  French 
translation,  by  Dr.  Laurent,  is  now  in  progress. 

1700  Walnut  St.,  PuiLAUKLriiiA, 
June,  1890. 


CONTENTS. 


INTRODUCTION. 

PAGE 

General  Considerations 17 

CHAPTER  I. 

EXAMINATION  OF  PATIENTS,  AND  SOME  SYMPTOMS  OF  GENERAL  IMPORT. 

General  Considerations  27 

Position  of  the  Body ,30 

General  Aspect — Expression  of  Countenance 31 

Skin 33 

Pulse 33 

Tongue , 40 

Sensations  of  Patients 43 

Temperature  of  the  Body 44 

CHAPTER  II. 

DISEASES   OP  THE   BRAIN   AND    SPINAL    CORD,  AND   OP  THEIR    NERVES. 

General  Considerations 52 

Cerebral  Localization .52 

Deranged  Intellection ,  58 

Delirium 58 

Stupor 61 

Coma 61 

Insomnia 62 

Deranged  Sensation 63 

Hypersesthesia 63 

Anaesthesia 65 

Headache 70 

Vertigo 72 

Derangement  of  Special  Senses 75 

Vision 75 

Hearing 86 

Deranged  Reflexes 86 

Deranged  Motion , 90 

Paralysis 90 

5 


6  CONTENTS. 


PAGE 


Hemiplegia 100 

Monoplegia 10G 

Paraplegia 1  T^ 

Sudden  Paraplegia HI 

Spinal  liemorrliage 1 1 1 

Aeute  Ascending  Paraly.-is 112 

Multiple  Neuritis 113 

Gradual   Paraplegia 115 

Spinal  Congestion 115 

Spinal  Aniemia 116 

Spinal  Meningitis 116 

Myelitis 117 

Spinal  Scleroses 119 

Tumors  of  the  Cord 121 

Keflex  Paraplegia '. 122 

Palsies  usually  Limited,  though  they  may  be  General 123 

Hysterical  Paralysis 123 

Rheumatic  Paralysis 125 

Lead  Palsy '. 125 

Diphtheritic  Paralysis 12(> 

Syphilitic  Paral\sis 126 

Local  Palsies 128 

Facial  Palsy 128 

Paralysis  of  the  Nerves  of  the  Arm 130 

Bulbar  Paralysis lol 

Palsies  connected  with  Marked  Muscular  Wasting 132 

Progressive  jNIuscular  Atrophy 133 

Infantile  Paralysis 137 

Ataxia 142 

Locomotor  Ataxia 142 

Diseases  of  the  Cerebellum 147 

Tremor •  148 

Paralysis  Agitans 148 

Multiple  Cerebro-spinal  Sclerosis 149 

Functional  Tremors 150 

Spasms— Convulsions 152 

Deranged  Nutrition  and  Secretion 154 

Acute  Affections  of  which  Delirium  is  a  Prominent  Symptom 159 

Acute  Meningitis 159 

Tubercular  Meningitis 164 

Cerebro-spi nal  Men ingi tis 169 

Delirium  Tremens 169 

Acute  Mania 171 

Diseases    mai'ked    l»y    Sudden    Loss  of  Consciousness    and    of  Voluntary 

Motion 173 

Apoplexy 173 

Sun-stroi<e 188 

Catalepsy 190 


CONTENTS.  7 

PAGE 

Diseases  marked  by  Convulsions  or  Spasms 191 

Epilepsy 191 

Chorea 190 

Hysteria 200 

Tetanus 204 

Punctional  Spasms 208 

Diseases  characterized  by  Gradual  Impairment  of  the  Mental  Faculties 

with  Paralysis 209 

Chronic  Softening 209 

Tumor : 218 

General  Paralysis 218 

Diseases  characterized  by  Enlargement  of  the  Head 220 

Chronic  Hydrocephalus „  220 

Hypertrophy  of  the  Brain 221 

Diseases  characterized  by  Paroxysmal  Pain 223 

Neuralgia  in  General 223 

Facial  Neuralgia 225 

Hemicrani  a 226 

Sciatica 227 


CHAPTER   III. 

DISEASES    OP   THE   UPPER   AIR-PASSAGES. 

General  Considerations ; 230 

Acute  Laryngeal  Affections 288 

Acute  Laryngitis 288 

(Edema  of  the  Glottis 240 

Croup 241 

Chronic  Laryngeal  Affections 248 

Chronic  Laryngitis 248 

CHAPTER    IV. 

DISEASES   OP   THE   CHEST. 
General  Considerations 256 

SECTION  I. 

DISEASES    or   THE    LUNGS. 

Different   Methods   of  Physical   Diagnosis,    and   the   Physical   Signs   of 

Pulmonary  Diseases 258 

Inspection  258 

Mensuration  259 

Palpation 262 

Percussion , 263 


8  CONTICNTS. 

PAGK. 

Auscultation -0'.' 

Sounds  of  Kespiration  in  Health  ami  in  Dii^oase 271 

t'lian^es  in  the  Vesicular  .Munnur "273 

]) lunch ial  Kespiration 277 

New  or  Adventitious  Sounds 279 

Auscultation  of  the  Voice 284 

Combination  of  the  Physical  Signs,  and  the   Examination  of  Patients 

affected  with  Disease  of  the  Lungs 285 

Principal  Symptoms  of  Diseases  of  the  Lungs 289 

Dyspnani  289 

Cough 294 

The  Sputa 297 

Htvmoptysis 297 

Diseases  in  which  Clearness  on  Percussion  is  met  with 301 

Acute  Bronchitis 301 

Chronic  Bronchitis 305 

Emphysema 308 

Diseases  in  which  Dulness  on  Percussion  occurs 313 

Phthisis 313 

Acute  Affections  of  the  Lungs  accompanied  by  Dulness  on  Percussion 338 

Acute  Phthisis 338 

Acute  Pneumonia 342 

Acute  Pleurisy 354 

Diseases  presenting  Dilatation  of  the  Chest,  Displacement  of  the  Liver  or 

Heart,  and  Dyspnoea 360 

Pneumothorax 361 

Chronic  Pleurisy 365 

Diseases  in  which  Retraction  of  the  Chest  occurs 372 

Chronic  Pletirisy 372 


SECTION  II. 

DISEASES    OF    THE    HEART. 

General  Considerations 376 

Examination  of  the  Heart  by  the  different  Methods  of  Physical  Diagnosis.  379 

Inspection  379 

Palpation 380 

Percussion  381 

Auscultation  383 

General  and  Local  Symptoms  of  Diseases  of  the  Heart 393 

Cardiac  Dropsy 394 

Derangement  of  the  Circulation 394 

Cardiac  Pain 396 

Palpitation 400 

Functional  Disorders  of  the  Heart 401 

Disorders    characterized    by    Palpitation,   associated   or   not   with 

Change  of  Rhythm ' 401 


CONTENTS.  9 


PAOE 


Organic  Diseases  of  the  Heart ;  400 

Acute  Diseases  presenting  Pain  in  the  Cardiac  Kegion  ;  Symptoms 
of  a  Disturbed  Circulation;   and  a  Change  in  the  iSounds 

of  the  Heart,  or  their  Keplacernent  by  Murmurs 407 

Acute  Endocarditis 408 

Acute  Pericarditis 414 

Myocarditis...., 423 

Chronic   Diseases   attended  with   Increased   Extent  of  Percussif^n 

Dulness,  but  with  Normal  or  almost  Normal  Heart-Sounds  424 

Hypertrophy 425 

Dilatation 428 

Fatty  Degeneration 430 

Pericardial  Effusion 434 

Diseases  of  the  Heart   exhibiting  more  or  less  of  the  Signs  and 
Symptoms  of  Enlargement  of  the  Organ,  and  accompanied 

by  Endocardial  Murmurs 435 

Valvular  Affections 435 

Displacements  of  the  Heart 449 


SECTION   III. 
Thoracic  Anedrism 450 


CHAPTER   V. 

DISEASES    OP    THE    MOUTH,    PHARYNX,    AND    (ESOPHAGUS. 

Mouth 462 

Fauces 465 

Tonsillitis 466 

Diphtheria 467 

Mumps 474 

Chronic  Sore  Throat 474 

Pharynx  and  (Esophagus 476 


CHAPTER    VI. 

DISEASES    OF    THE    ABDOMEN. 

General  Considerations 481 

Methods  and  General  Results  of  Physical  Examination  of  the  Abdomen..  482 

Inspection 482 

Palpation 483 

Percussion 484 

Aviscultation  489 


1 0  CONTENTS. 

SECTION  I. 

DISEASES   OK   TIIK   STOMACH. 

PAGE 

General  Considerat ions 490 

Loss  of  Appetite ;... 492 

Excessive  Acidity  of  the  Stomach 493 

Fhitulency 494 

Nausea  and  Voiiiiting 495 

Pain 502 

Diseases  of  the  Stomach  in  which  Pain  and  Soreness  at  the  Epigastrium, 

and  Vomiting,  occur 508 

Acute  Gastritis 508 

Chronic  Diseases  attended  with  Pain,  Epigastric  Tenderness,  and  Vomiting.  512 

Chronic  Gastritis  512 

Gastric  Ulcer 514 

Gastric  Cancer 518 

Dilatation  of  the  Stomach 526 

SECTION  11. 

DISEASES   OF   THE    INTESTINES    AND    OF    THE    PERITONEUM. 

General  Considerations 527 

Alvine  Discharges 527 

Diseases  attended  with  Paroxysms  of  Pain  referred  chiefly  to  the  Middle 
or  Lower  Part  of  the  Abdomen,  and  not  associated  witli  marked 

Tenderness,  or  with  Fever 530 

Colic •••  530 

Diseases   attended  with   Pain   and  marked    Tenderness  in  the  Umbilical 

Kegion  or  diffused  over  the  Abdomen  540 

Acute  Enteritis , 540 

Acute  Peritonitis 543 

Chronic  Peritonitis 555 

Diseases  attended  with  Pain  and  Tenderness  in  the  Eight  Iliac  Fossa 556 

Affections  of  the  Cajcum  and  its  Appendix 550 

Diseases   attended    with    Constipation,  and  of  which    it   is  a  Prominent 

Symptom 563 

Intestinal  Obstruction 563 

Habitual  Constipation  573 

Disordei-s  in  which  Morbid  Discharges  from  the  Bowels  occur 575 

Diarrhoea  576 

Dysentery 579 

Intestinal  Hemorrhage,  or  Melffina 582 

Fatty  Diarrhoea 584 

Diseases  attended  with  Vomiting  and  Purging 585 

Cholera  Infantum 585 

Cholera  Morbus 586 

Cholera 587 


CONTENTS.  1 1 

SECTION  III. 

DISEASES    OF    THE    LIVEK. 

PAGE 

General  Considerations , 592 

Jaundice 592 

Acute  Diseases  of  the  Liver  attended  generally  with  Slight  Enlargement 
of  the  Organ,  and  with  more  or  less,  though  rarely  verj'  mucli, 

Jaundice 598 

Acute  Congestion 598 

Acute  Hepatitis 598 

Inflammation  of  the  Gail-Bladder  and  Gall-Ducts 604 

Acute  Diseases  characterized  by  a  Decrease  in  the  Size  of  the  Liver,  and 

by  Deep  Jaundice 607 

Acute  Yellow  Atrophy 607 

Chronic   Diseases   attended   with   Enlargement   of  the   Liver,  and   with 

slight  or  no  Jaundice 610 

Chronic  Congestion 610 

Chronic  Hepatitis 612 

Abscess  of  the  Liver 613 

Fatty  Liver 618 

Waxy  Liver 619 

Cancer  of  the  Liver 620 

Hydatids  of  the  Liver 628 

Chronic   Diseases   attended  with  Decreased   Size  of  the  Liver  and  with 

Abdominal  Dropsy 633 

Cirrhosis 633 

Chronic  Atrophy  of  the  Liver , 639 


SECTION  IV. 

ABDOMINAL    ENLARGEMENT. 

General  Abdominal  Enlargement  640 

Ascites 640 

Chronic  Tympanites 647 

Partial  Abdominal  Enlargement 648 

Abdominal  Tumors 648 


SECTION  V. 

ABDOMINAL   PULSATION, 

Aortic  Pulsation 661 

Abdominal  Aneurism  661 


12  CONTENTS. 

CHAPTER    VII. 

ON    THE   URINE,    AND    ON    DISEASES    OF   THE    URINARY    ORGANS. 

PARE 

Urine  UCo 

Color 0U8 

Specific  Gravity (j(i9 

Reaction 671 

Changes  in  the  Quantity  of  the  more  Important  Constituents 673 

Presence  of  Abnormal  Substances  in  the  Urine 086 

Sediments 70!( 

Urinary  (.)rgans 712 

Diseases  of  the  Kidney  of  which  Pain  is  a  Prominent  Symptom 712 

Nephritis 712 

Nephralgia 713 

Diseases  marked  by  an  Albuminous  Condition  of  the  Urine,  with 

more  or  less  Drops\- 718 

Acute  Bright's  Disease 718 

Chronic  Bright's  Disease 726 

Diseases  associated  with  Purulent  Urine 742 

Acute  Cystitis 743 

Chronic  Cystitis 744 

Absce~ss  of  the  Kidney 744 

Pyelitis 747 

Disorders  in  which  a  very  large  Amount  of  Urine  is  discharged 751 

Diabetes 751 

Chronic  Diuresis 754 

Disorders  in  which  little  or  no  Urine  is  discharged 756 

Suppression  of  Urine 756 

Retention  of  Urine 757 


CHAPTER  VIII. 

DROPSY. 

Dropsy,  according  to  its  Seat  and  Extent 758 

Dropsy,  according  to  its  Causation 760 

Dropsy,  according  to  the  Rapidity  of  its  Development 762 


CHAPTER   IX. 

DISEASES   OF   THE    BLOOD-VESSELS. 

Diseases  of  the  Arteries 763 

Arteritis... 763 

Atheromatous  Changes 765 


CONTENTS.  13 

PAOK 

Diseases  of  the  Veins  706 

Phlebitis im 

Diseases  of  the  Capillaries 766 


CHAPTER  X. 

DISEASES    OF   THE    BLOOD. 

General  Considerations  768 

Ansemia 778 

Pernicious  Ansemia 779 

Leukaemia  784 

Addison's  Disease 788 

Pyaemia 791 

SepticEemia 794 

Thrombosis  and  Embolism 795 

Scurvy 801 

Purpura 802 


CHAPTER   XI. 

RHEUMATISM    AND    GOUT. 

Acute  Eheumatism ,.  804 

Chronic  Rheumatism 808 

Gout 812 

Rheumatic  Arthritis  or  Eheumatic  Gout 815 

Rickets 816 


CHAPTER  XII. 


FEVERS. 


General  Considerations 820 

Continued  Pevers 822 

Simple  Continued  Fever 822 

Catarrhal  Fever 823 

Typhoid  Fever 825 

Typhus  Fever  ..., 839 

Cerebro-spinal  Fever 847 

Relapsing  Fever 854 

Periodical  Fevers 857 

Intermittent  Fever 858 

Remittent  Fever 863 

Congestive  Fever 872 

Yellow  Fever 880 


14  CONTENTS. 

lUGK 

Eruptive  Fevers 880 

Scarlet  Fever 880 

Measles 801 

Rubella 895 

Smallpox 890 

Dengue 902 

Erysipelas 904 


CHAPTER   XIII. 

DISEASES   OP    THE    SKIN. 

General  Considerations 907 

Erythematous  Diseases 909 

Papular  Diseases 911 

Vesicular  Diseases 912 

Bullous  Diseases 91.5 

Pustular  Diseases Dl-S 

Squamous  Diseases 917 

Maculw 919 

New  Growths 919 

Hypertrophies 921 

Parasitic  Diseases 923 

Altered  Gland-secretions 925 

Nervous  Affections 920 


CHAPTER  XIV. 

POISONS    AND    PARASITES. 

Poisons 928 

Acute  Poisoning 928 

Irritant  Poisons 928 

Narcotic  Poisoning 932 

Chronic  Poisoning 938 

Parasites 949 

Vegetable  Parasites 949 

Animal  Parasites 950 

Index 909 


LIST  OF  ILLUSTRATIONS. 


FIG 
]. 

2. 

3. 

4. 


10. 
11. 
12. 

13. 
14. 
15. 
16. 
17. 
18. 
19. 
20. 
21. 

22. 
23. 

24. 
25. 

26. 

27. 


28. 
29. 
30. 
31. 


PAGE 

Sphygmograph  of  Mnrey 38 

Ordinary  Thermometer  for  Clin- 
ical Purposes 45 

Self-registering  Thermometer 45 

Seguin's  Surface  Thermometer....     45 

The  Thermoscope 45 

The  Centres  in  the  Human  Brain.     55 
Right    Homonymous    or    Lateral 

Hemianopsia 57 

The  ^sthesiometer 68 

Mathieu's  Dynamometer 95 

Laryngoscopes  232 

Laryngoscopic  Examination 233 

Laryngeal  Image,  as  seen  in  the 

Laryngoscope 234 

The  Stethometer 260 

The  Stetho-Goniometer 261 

The  Pleximeter 263 

Percussion  Hammer 265 

The  Ordinary  Stethoscope 270 

Hawksley's  Stethoscope 270 

The  Double  Stethoscope 271 

The  Differential  Stethoscope 271 

Diagram  illustrative  of  the  Main 
Forms  of  Feeble  Respiration...  274 

Diagram  illustrative  of  Rales 280 

Appearance  of  the  Chest  in  Em- 
physema    309 

Tubercle-Bacilli  in  Sputum 315 

Commencing        Infiltration        in 

Phthisis 319 

Cavities  in  the  Lung  in  Phthi- 
sis    320 

Diagram  illustrative  of  Perfect 
Pulmonary  Consolidation,  sucli 
as  occurs  in  the  Second  Stage 

of  Pneumonia 344 

Pneumocoocus    (Diplococcus)    of 

Friedlander  350 

Roughening  of   the  Pleura  from 

Inflammation 354 

Large     Effusion    occupying     the 

Left  Pleural  Cavity 356 

Physical  Signs  of  Pneumothorax.  362 


FIG. 

32. 


PAGE 

Topography  of  the  Heart 377 

Diagram  showing  the  Points  at 
which     the     Separate    Valves 

may  be  listened  to 384 

Position  of  the  Heart,  and  Dis- 
tention    of     the     Pericardium 

with  Fluid,  in  Pericarditis  415 

Hypertrophied  Heart,  lying  in  iis 

Position  in  the  Chest 426 

Dilated  Heart,  the  Right  Ventri- 
cle opened 430 

Narrowing  of  the  Aortic   Orifice 

by  Vegetations 439 

Insufficient  Mitral  Valves  per- 
mitting   Regurgitation  of  the 

Blood...; 441 

Sphygmogram  of  Aortic  Insuffi- 
ciency   443 

Sphygmogram  of  Mitral  Regur- 
gitation    443 

Results  of  Abdominal  Percussion.  488 

Sarcinse  Ventricuii 498 

Comma-Bacillus    of    Koch,    from 

Culture  in  Blood-Serum 589 

Ureometer 674 

Greene's  Ureometer..... 675 

Crystals  of  Uric  Acid 677 

Mixed  Urates 679 

Earthy  Phosphates  in  the  Urine..  681 

Calcium  Oxalate  Crystals.., 687 

Pus-Corpuscles 707 

Epithelial  Casts  and  Cells  from 
the  Kidneys  in  a  Case  of  Acute 

Bright's  Disease 720 

Fatty  Casts  and  Epithelial  Cells 
filled  with  Fat,  as  seen  in  Dis- 
charge from  a  Fatty  Kidney...   735 
Hyaline  or  Waxy  Casts  from  the 

Urine 737 

Granular  Casts,  or  Casts  covered 
with  Disintegrating  Epithe- 
lium and  Granules 738 

Artificial   Capillary  of   Malassez. 

Magnified  100  Diameters 770 

15 


IG 


LIST   OF    IIJATSTRATIONS. 


FIG 

56. 


58. 


59. 

60. 
61. 
62. 

63. 
64. 

65. 


PAGE 

Potain's  Pipette 771 

Graduated  Moist-Chamber  of  Ma- 

lassez "72 

Blood-Mixture,  as  seen  with  tlie 
Square   Micrometer    Ruling  of 
the  Moist-Chamber  of  Malassez.  773 
Hfemoglobinometer  of  Gowers....  776 

Blood  in  Pernicious  Anivmia 782 

Temperature  in  Typhoid  Fever...  82S 
Gall'ky's  Typhoid-Fever  Bacillus, 

from  a  Potato  Culture 830 

Spirilla  of  Relapsing  Fever 856 

Temperature  in  Tertian  Intermit- 
tent Fever 860 

Temperature  Chart  in  Remittent 
Fever 864 


FIG.  PAGE 

66.  Pigment  in  the  P.lood  in  Malarial 

Cachexia 869 

67.  Iltematozoa  of  Malaria S7I 

6S.  Temperature  in  Yellow  Fever 883 

69.  Temperature  in  Variola 898 

70.  Temperature  in  ^'arioloid 902 

71.  Acarus  Scabiei 924 

72.  Segments  of  Ttvnia  Solium 953 

73.  Heads  of  Ta;nia3 953 

74.  Trichina  in  Recent  IIumanMuscle.  958 

75.  Trichina  Capsule   with  Shell-like 

Calcareous  Deposits 959 

76.  Encapsuled    Chalky    Concretions 

in  Muscle,  due  to  Trichinaj 960 

77.  Trichina  Spiralis.    Magnified  300 

times 962 


MEDICAL  DIAGNOSIS. 


INTRODUCTION. 

GENERAL   CONSIDERATIONS. 

The  study  of  any  complicated  subject  leads  of  necessity  to  its 
arrangement  into  branches.  Closely  connected  as  these  are,  and 
forming  always  parts  of  a  whole,  they  are  not  only  capable  of 
distinct  treatment,  but  frequently  become  more  intelligible  as  they 
are  so  treated.  This  is  made  very  manifest  in  investigating  dis- 
ease. The  extent  of  ground  covered  by  the  inquiry  has  rendered 
it  imperative  to  map  it  out  into  various  provinces,  which,  however 
intimately  united,  may  be  with  convenience  separately  surveyed. 
One  comprises  the  laws  and  facts  common  to  individual  aifec- 
tions  ;  in  another  are  gathered  together  all  relating  to  their  causes ; 
another  embraces  the  consideration  of  their  detection  and  the  full 
recognition  of  their  nature.  It  is  the  purpose  of  these  pages  to 
examine  this  department  somewhat  minutely,  and  especially  that 
portion  of  it  coming  within  the  range  of  the  practitioner  of  med- 
icine. In  so  doing  it  will  become  apparent  how  diagnosis,  for 
such  the  distinction  of  disease  is  technically  called,  is  partly  a 
science,  partly  an  art ;  a  science,  because  it  comprehensively  takes 
account  of  general  facts,  and  of  principles  based  on  those  facts ; 
an  art,  because  it  demands  a  cognizance  of  the  means,  and  their 
application  to  arrive  at  the  desired  result. 

To  consider,  then,  medical  diagnosis  in  all  its  bearings,  it  will 
be  necessary  not  only  to  hold  up  to  view  the  morbid  states  met 
with  in  the  examination  of  the  sick,  but  also  to  inquire  in  M'hat 
manner  they  may  be  most  readily  recognized  and  explored,  and 
how  their  differences  may  be  made  available  in  the  discrimination 

2  17 


18  MEDICAL    DIAGNOSIS. 

of  0110  ailment  from  another.  In  a  study  of  this  kind,  an  inves- 
titrati(tii  of  syni[)toins  pUiys  unavoidably  a  prominent  part.  In 
truth,  the  deteetion  of  disease  is  the  produet  of  elose  observation 
of  symptoms,  and  of  eorreet  deduction  from  those  symj^toms. 

The  first  re(piiremeiit  therefore  for  an  accurate  dia^iinsis  is  to 
learn  to  recognize  morbid  signs.  But  the  art  of  observation  this 
implies  is  not  easy,  and  cannot  be  thoroughly  acquired  except  by 
practice.  Xo  one  aspiring  to  become  a  skilful  observer  can  trust 
exclusively  to  the  light  reflected  from  the  writings  of  others :  he 
must  carry  the  torch  in  his  own  hands,  and  himself  look  into 
every  recess.  The  knowledge  obtained  from  reading  is,  however, 
serviceable  in  this  way  :  it  aids  in  overcoming  one  of  the  main 
difficulties  at  first  experienced, — to  know  where  to  look  and  what 
to  look  for.  There  are  in  almost  every  affection  some  symptoms 
which  can  hardly  escape  the  merest  beginner;  but  also  some 
which  do  not  appear  on  the  surface,  and  which  to  find  taxes  the 
skill  of  tlie  experienced  physician.  And  it  is  especially  in  this 
search  after  hidden  signs  that  medical  information  as  well  as  cul- 
tivated tact  is  demanded. 

Now,  to  recognize  the  manifestations  of  disease,  whether  they 
are  or  are  not  readily  jierceptible,  we  have  to  employ  our  eyes  and 
ears,  our  sense  of  touch  and  of  smell.  Formerly  we  could  go  no 
further  than  these  senses  unassisted  would  carry  us.  But  science 
has  lent  its  aid,  and  furnished  means  by  the  help  of  which  we  can 
detect  clearly  what  before  we  could  not  detect  at  all,  or  that  of 
which  at  best  we  caught  only  a  glimpse.  AVe  now  possess  instru- 
ments by  M'hich  ^ve  ascertain  with  accuracy  the  size  of  organs  and 
their  play.  AVith  thermometers  we  tell  to  a  fraction  of  a  degree 
the  heat  of  various  parts  of  the  body.  Sj^ecific-gravity  bottles, 
and  other  measures  devised  for  the  purpose,  inform  us  of  the 
relative  gravity  of  fluids.  The  microscope  gives  at  a  glance 
insight  into  matters  which  the  naked  eye  fails  even  to  perceive, 
shows  us  crj'stals  in  secretions,  enables  ns  to  count  the  corpuscles 
in  the  blood,  and  to  detect  minute  and  disease-causing  specific 
organisms.  The  laryngoscope  demonstrates  the  appearance  and 
the  movements  of  the  organ  of  speech.  The  ophthalmoscope 
informs  ns  of  the  state  of  the  vessels  in  the  brain.  And  chem- 
istry, with  its  marvellous  teachings,  is  rendering  our  knowledge 
of  many  morbid  states  amazingly  complete.     Then  the  sagacity 


GENERAL   CONSIDERATIONS.  19 

of  comparatively  modern  times  has  taught  us  to  enlist  the  sense 
of  hearing,  and  demonstrated  how  a  disciplined  ear  may  detect 
the  workings  of  disease  in  cavities  into  which  the  eye  cannot 
penetrate.  The  effect  of  all  these  improved  methods  of  study  has 
been  to  give  an  immense  impetus  to  clinical  research,  and  thus 
to  lead  to  the  construction  of  a  solid  groundwork  of  experience 
in  striking  contrast  with  the  looseness  of  former  times.  The 
advance  in  diagnosis  thus  attained  forms,  indeed,  one  of  the  most 
pleasing  portions  of  medical  history. 

When,  by  means  of  the  aided  or  unaided  senses,  the  symptoms 
of  the  malady  have  been  discovered,  the  next  step  toward  a  diag- 
nosis is  a  proper  appreciation  of  their  significance  and  of  their 
relation  toward  one  another.  Knowledge  and,  above  all,  the 
exercise  of  the  reasoning  faculties  are  now  indispensable.  The 
daily  habit  of  investigating  disease ;  a  scrutinizing  study  of  the 
anatomical  lesions ;  chemistry,  with  its  most  searching  analyses  ; 
the  microscope,  with  the  wonders  it  reveals, — are  all  of  little  use, 
unless  we  have  been  taught  the  necessity  of  placing  in  connec- 
tion with  one  another  the  morbid  signs  they  lay  bare,  and  of 
considering  in  individual  cases  their  respective  value.  Were  it 
otherwise,  the  science  of  diagnosis  would  be  simply  a  matter  of 
memory.  It  is,  however,  this  very  analysis  of  symptoms  and 
the  lengthy  process  of  induction  attending  it  which  make  med- 
ical diagnosis  so  difficult  and  so  unattractive  to  the  beginner. 
He  sees  that  by  reflecting  and  reasoning  on  what  are  frequently 
but  indirect  manifestations  he  must  find  the  seat  and  nature  of 
disorders  hidden  from  his  view.  Nor  is  it  reasoning  on  the 
ascertained  facts  alone  that  is  required  ;  the  premises  may  be  but 
probabilities ;  for,  in  truth,  diagnosis  deals  at  times  with  the  logic 
of  probabilities  as  much  as  with  the  logic  of  patent  facts. 

Now,  we  are  greatly  aided  in  appreciating  morbid  signs,  and  in 
interpreting  them  correctly,  by  already  existing  knowledge.  We 
look  to  landmarks  which  our  predecessors  have  erected,  and  the 
gradually  accumulated  science  of  semeiology,  rightly  employed, 
furnishes  the  clue  to  the  discovery  of  the  disease.  Thus  the  stores 
which  medicine  has  laboriously  collected  during  centuries  can  be 
used  with  advantage  by  all,  and  exist  for  the  good  of  all. 

But  an  acquaintance  with  semeiology  is  far  from  being  the  sole 
guide  to  diagnosis,  nor  does  it  at  once  help  to  a  recognition  of  the 


20  MEDICAL   DIAGNOSIS. 

malady.  There  are  few  symptoms  in  themselves  distinctive  ;  and 
often  a  symptom  may  be  due  to  one  of  several  causes.  Semeiology 
informs  us  of  these  different  causes ;  but  to  find  out  the  precise 
meaning  of  the  abnormal  manifestation  in  an  individual  case,  we 
have  to  draw  our  inference  from  all  tlie  signs  encountered  ;  to 
compare  them  with  one  another ;  to  seek  out  those  that  are  in  the 
background.  We  are  thus  arriving,  step  by  step,  at  the  explana- 
tion of  the  morbid  appearances,  the  starting-point  in  deduction 
always  being  what  is  kno\vn  of  the  aifection  the  presence  of  which 
is  suspected,  and  the  symptoms  of  which  Ave  are  contrasting  with 
those  before  us.  For  the  conclusion  to  be  valid  and  exact,  it  is 
of  course  requisite  that  each  part  of  the  testimony  have  the  proper 
position  assigned  to  it.  In  reasoning  correctly  on  symptoms,  the 
same  laws  apply  as  in  reasoning  correctly  on  any  other  class  of 
phenomena :  the  facts  have  to  be  sifted  and  weighed,  not  merely 
indiscriminately  collected.  And  while  tlie  intellectual  act  is  being 
performed,  much  collateral  evidence  is  to  be  sought  before  a  final 
judgment  is  given ;  especially  is  it  necessary  to  view  the  symp- 
toms with  constant  reference  to  the  age,  sex,  and  habits  of  the 
patient,  and  to  the  circumstances  amid  which  the  disorder  develops. 
To  accomplish  all  this  eifectually,  the  physician  has  need  of 
much  and  varied  knowledge.  He  must  be  master  of  something 
more  than  of  the  information  supplied  to  him  by  semeiology. 
He  must  be  an  anatomist  to  pronounce  with  certainty  on  the  seat 
of  the  malady ;  a  physiologist  to  appreciate  the  state  of  the  great 
centres  and  the  aberration  of  function.  Above  all,  he  must  be  a 
pathologist  in  the  full  sense  of  the  term  :  he  must  understand 
the  antagonism  between  diseases ;  the  frequency  with  which  they 
coexist ;  the  influence  of  remedial  agents  on  them  ;  and  be  cogni- 
zant of  their  natural  history  and  of  the  general  laws  governing 
them, — for  how  else  can  he  form  an  estimate  of  morbid  action 
while  in  progress?  Then  it  is  desirai:)le  that  he  should  be  aware 
of  what  are  their  current  divisions  and  classifications.  From 
what  has  already  been  represented,  it  is  evident  that  he  must 
also  be  a  correct  reasoner ;  for  even  a  good  observer  will,  by  bad 
reasoning,  arrive  at  a  faulty  diagnosis ;  just  as  sometimes  a 
bad  observer  may,  by  the  same  process,  blunder  into  the  truth. 
There  is,  indeed,  no  end  to  the  extent  of  knowledge  which  may  be 
brought  to  bear  in  working  out  a  conclusion  regarding  the  char- 


GENERAL   CONSIDERATIONS.  21 

acter  and  seat  of  a  malady.  The  habit  of  observation  once  ac- 
quired, information  of  the  most  varied  kind  will,  by  an  accurate 
reasoner,  be  made  tributary  to  the  completeness  of  the  diagnosis. 
Every  fresh  acquirement  tends  to  enlarge  our  powers  of  insight. 
Just  as  in  nature,  the  higher  we  ascend,  the  more  fully  lies  the 
view  before  us. 

Having  thus  indicated  the  elements  of  a  thorough  diagnosis, 
we  may  next  inquire  in  what  way  this  is  most  easily  arrived 
at  when  at  the  bedside.  The  main  facts  of  the  case  on  which 
the  deductions  are  to  be  based  are  of  course  first  elicited.  We 
lay  hold  of  these  main  facts,  and  especially  of  those  which  are 
the  most  direct  signs  of  the  morbid  action.  They  are  coupled 
together,  and  the  inquiry  is  started  as  to  what  organ  they  indicate 
as  the  seat  of  the  malady.  This  often  has  been  already  deter- 
mined by  the  very  method  of  the  examination ;  and  we  therefore 
proceed  at  once  to  investigate  the  precise  nature  of  the  disorder 
by  analyzing  the  symptoms  and  the  previous  history.  Some- 
times, however,  the  site  of  the  disease  does  not  admit  of  being 
definitely  fixed  upon,  or  we  can  only  in  a  general  manner  decide 
upon  the  function  impaired.  Again,  as  in  idiopathic  fevers,  we 
may  find  no  signs  of  local  disease, — merely  those  of  a  general 
disturbance.  In  any  of  these  instances  clinical  experience  steps 
in  to  explain  the  phenomena  as  far  as  possible,  and  to  inform 
us  in  what  aiFections  they  occur.  It  may  be  only  in  one ;  then 
the  desired  goal  is  at  once  attained.  But,  as  above  stated,  there 
are  few  signs  in  themselves  pathognomonic.  It  is  therefore  to 
be  ascertained  Avhich  one  of  the  disorders  is  before  us  that  special 
pathology  teaches  may  yield  the  symptoms  encountered.  One 
of  these  is  taken  up.  Its  symptoms  are  placed  side  by  side  with 
those  present.  They  accord  in  some  respects,  but  not  in  all. 
Moreover,  in  searching  for  some  of  the  phenomena  which  the 
supposed  malady  gives  rise  to,  these  are  not  found.  The  view  is 
abandoned,  and  another  taken  up.  It  agrees  in  all  particulars. 
"The  diagnosis  is  made.  Yet,  when  the  diagnosis  is  thus  arrived 
at,  we  have,  before  it  can  be  considered  as  complete  and  be  acted 
upon,  still  to  determine  whether  or  not  any  other  morbid  state 
exists,  and  to  take  into  account  the  patient's  general  condition 
and  his  individuality. 

To  cite  a  case  in  illustration.     A  person  consults  us  for  a  cough 


22  MEDICAL    DIAGNOSIS. 

brought  on  by  exposure.  Ho  has  been  ill  for  four  or  five  days, 
haviiiij;  been  previously  in  good  health.  AVc  notiee,  on  examining 
him,  that  his  breathing  is  hurried,  and  that  he  has  fever ;  the 
lower  portion  of  one  side  of  the  chest  is  dull  on  })ereussion,  and 
the  respiration  there  is  wanting ;  the  action  and  sounds  of  the 
heart  are  normal.  The  facts  point  to  the  lung  or  its  covering  as 
the  seat  of  the  disorder.  We  know,  furthermore,  from  the  his- 
tory and  the  febrile  symptoms,  that  we  have  to  deal  with  an  acute 
affection.  What  are  the  acute  pulmonary  affections  ?  Acute  bron- 
chitis ;  acute  phthisis  ;  acute  pleurisy  ;  acute  pneumonia.  In  all 
occur  fever,  cough,  and  impaired  breathing.  Is  it  acute  pneu- 
monia? No;  for,  notwithstanding  there  is  in  this  complaint,  in 
addition  to  the  general  symptoms  mentioned,  dulness  on  per- 
cussion, the  dulness  is  associated  with  a  blowing  respiration ; 
whereas  in  the  case  before  us  no  respiration  is  heard.  Let  us 
look  at  the  sputum,  and  see  if  it  be  tenacious  and  rusty-colored. 
It  is  not ;  it  is  thin  and  frothy.  But  acute  pleurisy  may  explain 
all  the  signs.  The  patient,  too,  when  questioned,  states  that  he 
had  at  the  onset  a  sharp  pain  in  his  side ;  and  this,  we  are  a\\are, 
takes  place  in  pleurisy.  The  vocal  vibrations,  likewise,  are  no- 
ticed to  be  absent  on  the  affected  side  of  the  chest,  M'liich,  when 
measured,  is  found  to  be  enlarged.  This  corresponds  in  all  points 
with  what  happens  in  pleurisy  in  the  stage  of  effusion.  The  dis- 
ease is,  therefore,  acute  pleurisy  in  the  stage  of  effusion.  AVe 
finish  the  diagnosis  by  ascertaining  the  existence  or  non-existence 
of  other  maladies,  and  by  taking  note  of  the  severity  of  the  com- 
plaint ;  that  it  has  occurred  in  a  young  and  robust  person  of 
good  habits ;  and  that  the  symptomatic  fever  is  very  active. 

This  process  of  arriving  at  an  opinion  is  the  simplest.  It  is 
one  in  whicli  the  investigation  of  the  case  is  to  some  extent  car- 
ried on  while  the  deductions  are  being  made.  And  it  is  astonish- 
ing how  rapidly  it  may  be  performed  by  habit.  The  mind  works 
unconsciously,  and  a  decision  is,  to  all  appearance,  formed  intui- 
tively, which  surprises  the  inexperienced  by  its  readiness  and  pre- 
cision. This  method  aims,  so  far  as  the  symptoms  permit,  at  a 
direct  diagnosis.  But,  in  truth,  it  is  often  what  is  called  difcren- 
tial :  that  is,  it  takes  cognizance  of  and  dwells  on  the  essential 
signs  by  which  one  disease  can  be  discriminated  from  another 
resembling  it. 


GENERAL    CONSIDERATIONS.  23 

Sometimes,  instead  of  attaining  the  desired  result  in  the  manner 
proposed,  we  are  obliged  to  judge  of  th2  nature  of  the  malady 
entirely  by  finding  out  what  it  is  not.  The  various  diseases  ca- 
pable of  producing  all,  or  even  some,  of  the  striking  symptoms 
observed,  are  enumerated.  They  are  one  by  one  considered  and 
set  aside,  until  by  this  process  of  pure  exclusion  the  mischief  is 
brought  to  light.  Thus,  to  use  again  the  example  just  given,  we 
should  have  to  assign  reasons  why  the  disease  is  neither  acute 
pneumonia,  nor  bronchitis,  nor  acute  phthisis,  and  in  this  way 
determine  it  to  be  acute  pleurisy.  But  to  prove  what  a  thing  is 
by  proving  all  that  it  is  not,  is  a  very  tedious  process,  and  we 
must  be  quite  certain  that  really  all  morbid  states  which  may  give 
rise  to  the  symptoms  encountered  are  thought  of  and  inquired  into  ; 
otherwise  our  conclusion  may  be  fallacious,  though  reasoned  out 
in  the  most  logical  manner.  Moreover,  our  knowledge  of  many 
pathological  conditions  is  so  imperfect  that  we  are  not  fully  cog- 
nizant of,  or  able  at  once  to  discern,  the  more  characteristic  signs ; 
nor  can  the  symptoms  be  taken  hold  of  and  arranged  in  such  a 
way  as  shall  permit  us  to  make  nice  distinctions  without  a  lengthy 
and  laborious  plan  of  procedure.  Owing  to  these  drawbacks, 
diagnosis  by  exclusion  is  not,  on  ordinary  occasions,  much  em- 
ployed, nor,  indeed,  is  it  to  be  recommended.  Yet  in  difficult 
and  obscure  cases,  where  the  accustomed  pathway  is  blocked  up, 
it  may  enable  us  to  pass  by  obstacles  otherwise  insurmountable. 

But  can  we  by  this  or  by  any  other  road  always  reach  a  certain 
diagnosis  ?  We  cannot,  and  for  several  reasons.  The  patient  may 
deceive  us,  wilfully  or  unintentionally.  It  may  be  necessary,  for 
the  confirmation  of  the  opinion  formed,  to  obtain  an  accurate  his- 
tory of  the  case,  and  circumstances  may  render  this  impossible. 
The  disorder  may  be  so  rare  that  its  symptoms  are  not  understood. 
There  may  be  several  lesions  present,  the  signs  of  one  masking 
or  neutralizing  the  signs  of  the  other. 

The  first  of  the  causes  mentioned  is  a  source  of  error  difficult 
to  guard  against.  To  escape  punishment,  to  avoid  disagreeable 
duty,  to  excite  compassion,  to  obtain  a  compliance  with  unreason- 
able wishes,  or  sometimes  from  the  mere  love  of  deception,  symp- 
toms may  be  stated  to  exist  which  do  not  exist,  or  may  be  imitated 
and  artificially  produced.  Persons  who  thus  feign  disease  are  nu- 
merous.    They  are  found  in  all  occupations  and  in  all  classes  of 


24  MEDICAL    DIAGNOSIS. 

society.  They  abound  in  the  army  and  navy.  Hysterical  women 
and  hypochondriacs  help  to  swell  the  list.  These,  indeed,  suifer 
mostly  some  inconvenience,  but  exaggerate  it  immensely,  and,  by 
deceiving  themselves,  end  by  deceiving,  unless  he  be  on  his  guard, 
their  physician.  On  the  other  liand,  disease  actually  in  progress 
may  be  carefully  concealed  from  motives  of  delicacy  or  from  fear 
of  tlie  consequences.  f 

An  incorrect  diagnosis  from  want  of  a  proper  history  does  not, 
on  the  whole,  occur  often.  Patients  are  generally  ver)-  Axilling  to 
give  a  full  account  of  themselves  and  of  their  distresses.  Some- 
times, however,  the  reverse  happens.  Pain  or  mental  anxiety  and 
sorro^v  may  be  wearing  the  body  out  while  the  sufferer  obstinately 
persists  in  hiding  the  cause  of  his  waning  health.  We  meet  also 
with  individuals  so  stupid  that  the  most  elaborate  cross-examina- 
tion fails  to  elicit  anything  like  a  connected  history.  Again,  we 
may  be  unable  to  do  so  from  the  patient  having  lost  the  power  of 
speech.  A  man  is  brought  into  a  hospital  unconscious.  It  is  of 
the  utmost  importance  to  know  how  long  he  has  been  in  this  state, 
and  what  were  his  prior  symptoms  :  unless  some  friend  can  supply 
the  information,  the  most  valuable  diagnostic  data  are  wanting. 

In  the  rarity  of  a  disease  we  have  a  serious  drawback  to  its 
recognition.  This  may  occasion  an  error  of  diagnosis  in  a  two- 
fold manner.  The  more  distinctive  symptoms  may  be  so  little 
understood,  and  the  prominent  features  so  nearly  identical  with 
those  of  a  malady  with  the  manifestations  of  ^^•llicll  we  are  well 
acquainted,  that  a  conclusion  of  the  presence  of  the  latter  forces 
itself  almost  immediately  on  the  mind.  Or,  the  disorder  may 
give  rise  to  phenomena  wholly  unknown,  nothing  but  the  autopsy 
revealing  their  true  meaning.  Every  physician  encounters  such 
cases.  It  is  true  that  the  progress  of  science  and  the  aggrega- 
tion of  clinical  facts  are  from  year  to  year  bringing  them  into  a 
narrower  circle.  Yet,  are  there  not  still  diseases,  nay,  groups 
of  diseases,  that  have  eluded  discovery  to  the  manifold  means 
of  research  of  the  present  day,  as  they  have  to  the  accumulated 
experience  of  the  past  ? 

But  the  most  serious  obstacle  to  a  precise  diagnosis  lies  in  the 
fact  that  frequently  lesions  coexist.  Disease  is  a  very  complex 
state,  and  when  one  portion  of  the  economy  gets  out  of  order,  an- 
other is  apt  to  follow.     How  close,  for  example,  the  connection 


GENERAL    CONSIDERATIONS.  25 

between  affections  of  the  heart  and  affections  of  the  kidney  ! 
Here  it  is  easy  to  arrive  at  a  conclusion,  since  we  have  the  means 
of  judging  accurately  of  the  condition  of  both  organs.  But  there 
are  instances  in  which  it  is  very  difficult,  especially  when  a  part 
contiguous  to  one  chronically  affected  is  attacked  with  acute  dis- 
ease. A  person  applies  for  relief,  presenting  all  the  symptoms  of 
a  severe  local  peritonitis.  The  inflammation  spreads ;  death  re- 
sults. The  exciting  cause  of  the  inflammation  is  discovered  to  be 
a  structural  alteration  of  one  of  the  abdominal  viscera,  the  signs 
of  which  were  completely  merged  in  the  more  marked  signs  of 
the  recent  inflammation.  And  this  disguisement  is  effected  not 
only  by  the  supervention  of  another  and  more  acute  complaint, 
but  also  sometimes  by  the  prominence  of  those  remote  sympa- 
thetic derangements  which  an  affection  of  any  viscus  may  produce. 
Thus,  the  disturbed  action  of  the  heart  in  dyspeptic  persons  throws 
at  times  the  symptoms  of  the  gastric  malady  into  the  shade.  Yet 
it  must  be  admitted  that  errors  of  diagnosis  from  this  source  are 
not  apt  to  occur  to  the  careful  practitioner.  A  thorough  exami- 
nation of  the  case  is  a  safeguard  against  them. 

These,  then,  are  the  various  causes  which  render  a  diagnosis 
uncertain,  or  wholly  unattainable.  Let  us  add  to  them  one  that 
does  so  temporarily.  There  are  disorders  the  early  manifestations 
of  which  are  so  much  alike  that  it  is  next  to  impossible  to  tell  with 
which  of  several  we  have  to  deal.  In  fevers  this  often  happens. 
Here,  however,  a  few  days,  or  even  less  time,  will  almost  always 
solve  the  difficulty.  But  not  so  in  other  diseases.  It  is  only  after 
a  much  longer  period,  and  by  careful  watching  of  the  patient,  that 
the  appearance  or  disappearance  of  a  striking  symptom,  or  the 
greater  prominence  a  hitherto  indistinct  sign  assumes,  inclines 
the  scales  toward  one  or  the  other  of  the  affections  between  which 
judgment  has  been  kept  in  suspense. 

In  some  such  instances,  the  treatment  becomes  the  touchstone 
of  the  diagnosis.  Now  it  may  be  asked,  Does  this  demonstrate 
that  the  diagnosis  of  a  case  is  not  necessary  for  its  treatment? 
Not  at  all.  It  simply  proves  that  we  are  sometimes  obliged  to 
aim  at  removing  symptoms  without  understanding  their  source. 
But  it  does  not  prove  that  if  we  understood  their  source  we  should 
not  be  better  able  to  remove  the  symptoms.  The  physician  who 
undertakes  to  relieve  disease  simply  by  attempting  to  allay  its 


26  MEDICAL    DIAGNOSIS. 

symptoms,  regardless  of  their  cause,  and  without  understanding 
their  true  relation  and  significance,  is  groping  in  tiie  dark.  His 
treatment  is  vacillating ;  drug  replaces  drug  ;  alleviation  is  taken 
for  a  cure ;  and  the  experience  obtained  is  utterly  untrustworthy. 
One  great  advantage,  indeed,  of  attending  carefully  to  diagnosis 
is,  that  it  enables  us  to  use  remedies  knowingly  and  with  decision  ; 
to  appreciate  what  they  are  effecting  ;  to  abstain  from  such  as  must 
be  injurious.  There  is  less  needless  meddling,  more  calmness ; 
the  treatment  rises  above  the  consideration  of  the  moment,  and 
takes  into  account  Avhat  is  for  the  patient's  ultimate  good.  It  is 
sometimes  urged  tliat  the  accurate  detection  of  disease  makes  timid 
practitioners,  and  deprives  thoni  of  confidence  in  medicines.  More 
just  is  it  to  say  that  it  shows  how  wide  is  the  chasm  between  our 
ae(|uaintance  with  morbid  conditions  and  our  acquaintance  with 
remedies ;  how  far,  unfortunately,  our  skill  to  detect  disease  still 
outruns  our  power  to  cure  it. 

There  is  undoubtedly,  however,  a  danger  w^hieh  may  arise  from 
paying  very  minute  attention  to  diagnosis.  The  study  of  it  is  so 
interesting,  and  capable  of  being  conducted  so  entirely  without 
reference  to  other  points,  and  especially  to  the  treatment  of  the 
complaint,  that  some  minds  are  carried  away,  and,  lost  in  the  pur- 
suit of  diagnostic  knowledge,  forget  for  what  purposes  chiefly  that 
knowledge  is  profitable.  Its  main  use  is  to  enable  us  to  fore- 
tell the  course  and  probable  issue  of  a  malady,  and  to  frame, 
with  iniderstancling,  plans  for  its  relief.  Nor  ought  we  ever  to  be 
unmindful  how  important  it  is,  in  basing  the  management  of  a 
disease  on  its  diagnosis,  to  found  that  diagnosis  on  a  general  sur- 
vey of  all  the  circumstances ;  how  necessary  not  to  assign  promi- 
nence to  minor  points  ;  and  how  the  extent  of  the  affection,  the 
circumstances  under  which  it  has  occurred,  the  sympathetic  dis- 
turbances produced,  and  the  vital  state  of  the  patient,  belong, 
rightly  considered,  quite  as  much  to  the  diagnosis  as  the  recog- 
nition of  the  precise  seat  and  exact  anatomical  character  of  the 
malady,  and  are,  in  truth,  frequently  its  more  im])ortant  part. 


CHAPTER   I. 

THE  EXAMINATION  OF  PATIENTS,  SYMPTOMS  OF  GENEPvAL 
IMPORT,  AND  SOME  OF  THE  INSTRUMENTS  EMPLOYED 
IN   THE    DIAGNOSIS. 

To  elicit  the  facts  of  a  case  by  a  careful  examination  is,  as  has 
been  stated,  the  first  requisite  for  diagnosis.  To  conduct,  however, 
a  clinical  inquiry  with  precision  and  facility,  requires  continual 
practice,  and  is  rendered  easier  by  following  some  well-digested 
plan.  The  advantage  of  adopting  a  method  is  clearly  seen,  if  the 
attempts  of  a  beginner  be  watched.  He  wanders  in  his  search 
from  one  part  of  the  body  to  another,  attracted  by  different  symp- 
toms in  turn ;  pointless  question  succeeds  to  pointless  question ; 
and  a  conclusion,  almost  certainly  erroneous,  is  finally  jumped  at, 
or  an  acknowledgment  made  of  inability  to  arrive  at  any. 

Now,  there  are  several  ways  which  have  been  proposed  to  over- 
come this  embarrassment.  One  of  the  principal  consists  in  first 
questioning  the  patient  with  regard  to  his  history.  His  age  ;  his 
occupation ;  the  diseases  from  his  childhood  up ;  his  habits ;  his 
constitution ;  the  affections  hereditary  in  his  family, — are  all 
minutely  inquired  into.  After  this  the  origin  and  progress  of  the 
existing  disorder  are  traced,  and  the  remedies  ascertained  that 
have  been  used  against  it.  The  present  condition  is  then  ex- 
plored ;  each  organ  or  each  system  being  in  turn  interrogated. 
The  investigation  is  now  regarded  as  complete ;  the  facts  are  con- 
sidered, and  the  diagnosis,  prognosis,  and  treatment  determined. 
This  method  of  examining  is  termed  the  synthetical  or  historical. 
The  analytical  reverses  the  order.  The  present  condition  is  first 
ascertained,  and  subsequently  the  patient's  history  or  anamnesis. 
Both  of  these  courses  have  something  to  recommend  them,  and 
to  both  there  are  objections.  The  synthetical  method  is  the 
more  purely  scientific ;  but  it  is  too  full,  and  calls  for  too  much 
labor,  to  meet  the  requirements  of  ordinary  professional  life.     It  is 


28  MEDICAL    DIAGNOSIS. 

nmoh  bettor  adapted  for  reeordino-  eases  in  the  pursuit  simply  of 
pathologieal  knowledge,  and  dceidedly  the  best  where  the  history 
is  obscure  and  the  symptoms  are  ill  defined.  The  plan  which  I 
habitually  prefer  is  to  take  a  general  survey  of  the  history  and  of 
the  prominent  symptoms,  and,  having  thus  obtained  some  clue  to 
the  part  most  likely  to  be  atiected,  to  explore  that  with  care.  For 
instance  :  we  are  brought  to  the  bedside  of  a  patient  for  the  first 
time ;  we  inquire  how  long  he  has  been  ill ;  how  that  illness 
began ;  in  what  way  he  is  now  disturbed, — whether  he  has  pain, 
or  what  is  the  main  source  of  his  annoyance.  AA'hile  questioning 
him,  we  are  scanning  his  appearance,  the  position  of  the  body, 
his  movements,  his  manner  of  breathing.  The  hand  is  applied 
to  the  skin ;  the  pulse  is  felt ;  the  tongue  is  looked  at ;  the  tem- 
perature is  taken.  Partly  from  this  examination  and  partly  from 
the  history,  some  organ  is  fixed  upon  to  be  specially  investigated : 
say  pain  in  the  epigastric  region  and  vomiting  are  complained  of, 
— our  attention  is  directed  to  the  stomach.  We  explore  this 
organ,  its  physical  state  and  its  functions.  Then  we  look  to  the 
parts  that  are  anatomically  or  physiologically  most  nearly  related 
to  it,  which  are,  in  the  case  cited,  the  intestines  and  liver.  The 
examination  is  completed  by  taking  heed  of  the  condition  of 
other  portions  of  the  body  ;  by  reviewing  the  history  of  the  case  ; 
and  by  endeavoring  to  elicit  fully  such  points  as  bear  upon  the 
diagnosis,  ■which  the  mind,  consciously  or  unconsciously,  has 
already  begun  to  frame.  Then  a  balance  between  the  symptoms 
is  struck,  the  diagnosis  is  recast,  modified,  or  extended,  and  the 
treatment  is  decided  upon. 

There  is  some  repetition  in  this  plan,  but  it  is  the  one  which 
appears  practically  the  most  suitable.  It  has  the  advantage  of 
bringing  together  the  marked  features  of  a  case,  and  especially 
those  most  clearly  indicative  of  the  general  or  vital  condition. 
But  whatever  scheme  be  chosen,  it  should,  for  us  to  become  pro- 
ficient in  it,  be  as  constantly  and  closely  adhered  to  as  the  varying 
circumstances  of  disease  will  permit.  Yet  thoroughly  to  acquire 
the  habit  of  examining  with  accuracy  and  care,  and  also  to  obtain 
tlie  full  fruits  of  experience,  it  is  indispensable  to  keep  written 
records.  This,  too,  should,  so  far  as  possible,  be  done  according 
to  a  uniform  design,  since  it  both  prevents  us  from  overlooking 
important  symptoms  and  enables  cases  to  be  more  readily  com- 


EXAMINATION    OF   PATIENTS,  ETC.  29 

pared.  I  subjoin  a  schedule  which  I  have  used  for  some  time, 
and  which  is  based,  as  closely  as  practicable,  on  the  plan  of  ex- 
amination just  mentioned. 

Date  of  Examination  ;  Name  ;  Age  ;  Color  ;  Place  of  Birth  ; 
Present  Abode ;  Occupation  or  social  state ;  In  females,  whether 
married  or  not,  number  of  children,  and  date  of  last  confinement. 

History, 

1.  History  antecedent  to  present  disease :  Con^t\t\xt\on  and 

General  Health — Hereditary  predisposition — Previ- 
ous Diseases  or  Injuries — Habits  and  mode  of  life; 
hygienic  influences  to  which  exposed,  etc. 

2.  History  of  present  disease :  Its  supposed  exciting  cause 

— Date  of  seizure — Mode  of   invasion  ;    subsequent 
symptoms   in   order  of  succession — Previous   treat- 
ment. 
Peesent  Condition  of  Patient. 

1.  General  symptoms  : 

-p.    ., .       f  in  bed — mode  of  lyine: ; 
Position  <  nil  J     b ' 

I  out  01  bed — movements ; 

.         ^  f  of  body  ; 
Aspect-^     f.        \ 

L  01  countenance ; 

Skin  ; 

Pulse ; 

Temperature ; 

Respiration — as  to  frequency,  etc. ; 

Tongue ; 

(  appetite ; 
General  state  of  Digestion  -I  thirst ; 

(  condition  of  bowels ; 
General  State  of  Urinary  Secretion ; 
Sensations  of  patient :  pain,  etc. 

2.  Examination  of  special  regions,  parts,  and  functions, 

beginning  with  the  one  presumably  the  most  affected, 
and  embracing,  whenever  practicable,  microscopical 
examination  of  the  blood. 

Diagnosis. 

Treatment. 
Remarks. 

The  history  is  here  placed  first ;  then  the  symptoms  of  general 


30  MEDICAL    DIAGNOSIS. 

import,  such  as  those  furnished  by  the  pulse,  the  tongue,  and  the 
temperature,  arc  made  to  precede  the  cxamiuation  of  special  regions. 
These  general  symptoms  arc  of  great  value  in  the  recognition  of 
disease,  and  of  yet  greater  vahie  in  determining  its  treatment. 
They  are  something  more  than  the  mere  physical  signs  of  textural 
aliections;  they  indicate  vital  conditions,  and  partly  from  their 
importance,  and  partly  from  their  not  being  linked  to  disease 
of  any  organ  in  particular,  they  demand  a  separate  and  detailed 
consideration. 

Position  of  the  Body. — By  noting  whetlier  the  patient  is  in 
bed  or  out  of  bed, — how  he  lies,  or  how  he  walks, — a  general  idea 
may  be  formed  as  to  the  acuteness  of  an  attack,  the  impairment  of 
strength  it  has  produced,  and  sometimes  even  as  to  its  nature.  Let 
a  person  who  has  been  actively  attending  to  his  usual  occupation 
be  suddenly  confined  to  his  bed,  and  the  inference  tliat  the  disease 
is  an  acute  and  a  severe  one  will  be  commonly  correct ;  certainly 
so,  if  no  mishap  to  the  organs  of  locomotion  have  necessitated  a 
resort  to  the  recumbent  position.  When  the  patient  lies  for  a  long 
time  on  his  back,  it  is  generally  from  exhaustion,  or  from  paralysis, 
or  it  is  owing  to  the  pain  which  pressure  or  motion  of  any  kind 
occasions.  Such  is  the  cause  of  the  dorsal  decubitus  in  peritonitis, 
and  in  rheumatism.  Lying  fixedly  upon  one  side  may,  as  a  rule, 
be  looked  upon  as  an  indication  that  the  action  of  the  lung  of 
this  side  is  impeded,  and  that  the  respiration  has  to  be  carried  on 
■with  the  other.  The  patient  may  be  confined  to  bed,  yet  unable 
to  lie  down  in  it,  on  account  of  the  distress  in  breathing  to  which 
the  recumbent  posture  giv^es  rise  :  he  leans  forward,  or  sits  erect. 
This  necessity  of  breathing  in  the  upright  position,  or  "  orthop- 
noea,"  is  a  form  of  dyspnoea  encountered  especially  in  diseases  of 
the  heart,  or  where  fluid  is  eifused  into  the  air-cells  or  into  both 
pleural  cavities. 

If  a  person  is  able  to  be  about,  his  posture  and  movements  be- 
come important  manifestations  of  his  condition.  The  young  and 
the  strong  Avallc  erectly,  quickly,  and  firmly ;  the  aged  and  the 
weak,  stoopingly,  slowly,  and  with  difficulty.  In  diseases  of  the 
spine  the  body  is  bent ;  so,  too,  in  affections  of  the  larger  joints  of 
the  lower  extremities. 

When,  after  a  fever,  or  any  other  prostrating  malady,  the  patient 
leaves  his  bed,  he  totters,  moves  slowly,  and  is  soon  obliged  to  rest : 


EXAMINATION    OF    PATIENTS,  ETC.  31 

returning  strength  brings  with  it  a  quicker  and  steadier  gait.  In 
some  diseases  of  the  brain  the  movements  are  staggering ;  in  one- 
sided palsy  they  are  uncertain,  and  the  affected  side  higs,  or  its 
motions,  if  it  can  be  moved  at  all,  are  laborious.  Excessive  and 
uncontrollable  movements  are  observed  in  mania  and  in  chorea ; 
trembling  motions  in  states  of  extreme  debility,  in  shaking  palsies, 
and  in  the  delirium  of  drunkards. 

General  Aspect — Expression  of  Countenance. — The  eye 
notices  rapidly  whether  the  body  is  bulky  or  wasted,  and  whether 
the  surface  is  discolored  or  otherwise  changed.  A  bulky  aspect 
of  the  whole  body  is  the  result  of  corpulency,  or  arises  from  uni- 
versal anasarca.  In  some  acute  diseases,  too,  a  general  tume- 
faction may  take  place, — for  example,  in  the  exanthemata.  A 
partial  increase,  or  a  swelling,  arises  from  the  local  extravasation 
of  fluid  or  air  into  the  cellular  tissues.  If  air,  the  tissues  crepi- 
tate under  the  finger ;  if  fluid,  the  skin  pits  under  pressure.  A 
swelling  may,  further,  proceed  from  an  inflammatory  thickening, 
or  from  a  tumor  or  any  morbid  groAvth. 

A  diminution  in  bulk  is  a  more  frequent  symptom  than  an 
augmentation.  It  may  lake  place  very  rapidly,  as  witnessed  in 
Asiatic  cholera. "  More  generally  the  wasting  is  gradual,  and  is  a 
sure  indication  of  the  nutrition  of  the  body  not  being  properly 
carried  on.  It  occurs  in  the  course  of  protracted  fevers,  and  in 
most  chronic  diseases.  In  dangerous  and  slowly  fatal  maladies, 
and  in  those  attended  with  constant  discharges, — for  instance,  in 
chronic  diarrhoea, — the  loss  of  flesh  reaches  its  highest  point. 

Emaciation  is  most  readily  recognized  in  the  face.  It  gives  rise 
to  that  significant  change  in  the  features  which  at  once  reveals  the 
existence  of  disease.  Not  that  emaciation  is  the  only  striking  alter- 
ation observable  in  the  countenance  when  health  has  failed.  There 
may  be  pallor,  sallowness,  a  livid  hue  of  the  lips,  a  puff'y  appear- 
ance of  the  eyelids,  a  flush  on  the  cheeks.  Now,  these  changes  in 
the  features,  added  to  the  expression  which  pain  or  special  trains 
of  thought  produce,  make  up  that  peculiar  physiognomy  of  disease 
so  pregnant  with  meaning.  But  I  shall  not  attempt  to  describe  in 
detail  the  cast  or  the  play  of  features  in  the  sick  :  the  shades  of 
expression  are  so  numerous  that  they  baffle  description,  and  are  to 
be  learned  only  by  continuous  bedside  experience.  I  shall  merely 
set  down  a  few  broad  facts  which  this  experience  teaches. 


32  MEDICAL    DIAGNOSIS. 

Among  the  countenances  most  frequently  met  with  is  that  of 
apatliy  and  stupor.  The  eye  is  dull  and  listless  ;  the  face  pale,  or 
flushed  with  fever.  This  look  is  conimou  in  fevers  of  a  low  type, 
and  is  often  combined  witli  Ijhickish  accumulations  on  the  lips, 
gums,  and  teeth. 

Unnatural fulness  and  congestion  of  the  features  are  sometimes 
observed  in  enlargements  of  the  heart,  and  oftener  still  in  habitual 
drunkards.  The  same  aspect  is  seen  in  apoplexy  and  in  typhus 
fever.  A  pinched  expression  is  found  when  there  is  intense  anx- 
iety or  pain,  or  a  wasting  malady  attended  with  constant  suffering. 
It  is  specially  observed  in  acute  peritoneal  inflammation.  AVhen 
very  marlced,  and  accompanied  by  change  of  hue,  it  is  the  face 
which  Hippocrates  has  so  graphically  described.  In  the  great 
master's  own  words,  "a  sharp  nose,  hollow  eyes,  collapsed  tem- 
ples ;  the  ears  cold,  contracted,  and  their  lobes  turned  out ;  the 
skin  about  the  forehead  being  rough,  distended,  and  parched  ;  the 
color  of  the  whole  face  being  green,  black,  livid,  or  lead-colored." 
This  is  the  physiognomy  of  approaching  death,  and  generally 
its  speedy  forerunner,  except  in  those  cases  in  which  the  expres- 
sion proceeds  from  want  of  food,  from  protracted  vigils,  or  from 
excessive  discharge  from  the  bowels. 

The  face  of  shock,  with  its  great  pallor,  its  anxious  or  frightened 
look,  and  its  fixed  or  oscillating  eye,  often  with  a  contracting  pupil, 
is  a  face  seen  after  severe  injuries,  and  as  such  familiar  to  the  sur- 
geon. But  in  many  of  its  main  traits  it  may  be  also  met  with  in 
diseases  that  make  a  sudden  and  overwhelming  impression  on  the 
nervous  system  ;  for  instance,  it  is  at  times  encountered  in  cerebro- 
spinal fever  and  in  cholera. 

An  aspect  serious  and  dull  on  one  side,  wliile  the  other  side  is 
in  full  play,  is  witnessed  in  some  instances  of  hemiplegia,  and  in 
paralysis  of  the  facial  branch  of  the  seventh  nerve.  The  differ- 
ence in  the  cast  of  the  features  may  escape  observation  when  the 
face  is  in  repose,  but  as  soon  as  an  attempt  is  made  to  laugh,  it 
shows  itself  plainly. 

Besides  these  lineaments,  which  may  be  said  to  be  common  to 
several  diseases,  we  read  frequently  in  the  countenance  the  signs 
of  special  disorders.  A  dusky  flush  on  the  face,  if  associated 
with  rapid  breathing,  is  almost  a  certain  indication  of  inflamma- 
tion of  the  lung.     Puffiness  of  the  eyelids  in  a  pallid  person  is 


EXAMINATION  OF  PATIENTS,  ETC.  33 

very  apt  to  be  expressive  of  Bright's  disease.  A  bluish  color  of 
the  lips  shows  plainly  that  the  venous  circulation  is  interfered 
with  or  that  the  blood  is  but  imperfectly  aerated.  Then  there  is 
the  straw-colored,  anaemic  hue  of  malignant  disease ;  tlie  jaun- 
diced, melancholy  look  of  an  hepatic  affection  ;  the  downcast 
expression  and  mobility  of  the  features  in  hysteria ;  the  thickened 
upper  lip,  delicate  skin,  and  fair  complexion  of  scrofula  ;  the 
sallow  countenance  and  peculiar  notched  teeth  which  indicate  in- 
herited syphilis ;  and  the  various  traits  which  tend  to  mark  not 
only  the  special  diathesis,  but  also  the  peculiar  temperament,  with 
the  morbid  tendencies  that  belong  to  it. 

Skin. — By  the  state  of  the  skin  we  can,  to  a  great  extent, 
judge  of  the  activity  of  the  circulation  and  of  the  character  of 
the  blood.  Moreover,  it  is  a  fair  index  of  the  secretions,  and  of 
the  condition  of  the  system  at  large.  In  fevers,  along  with  the 
quickened  circulation,  the  temperature  of  the  skin  is  increased ; 
the  attending  dryness  is  produced  by  defective  perspiration. 
Coldness  of  the  surface  indicates  a  weakened  capillary  circula- 
tion, and  is  met  with  at  the  invasion  of  acute  diseases,  and  when 
the  nervous  power  is  under  the  sway  of  some  highly  deleterious 
influence.  If  heat  of  surface  succeed  a  cold  skin,  we  know  that 
reaction  has  taken  place,  that  the  circulation  has  again  become 
active.  Protracted  coldness,  whether  attended  with  dryness  or 
with  clamminess,  is  of  evil  augury  :  it  implies  seriously  dimin- 
ished vital  force. 

The  cutaneous  covering  is  pale  whenever  the  blood  is  poor  and 
watery.  If  this  be  seriously  vitiated  and  largely  deprived  of  its 
fibrin,  as  in  putrid  fevers,  black  spots  are  seen^  due  to  extrava- 
sation. Ofttimes  the  surface  is  overspread  with  eruptions,  some 
of  which  bear  a  close  relation  to  disorders  of  internal  organs,  while 
others  are  connected  with  febrile  or  general  maladies ;  and  others, 
again,  are  owing  to  a  disease  of  the  texture  itself. 

Tension  of  the  skin  is  met  with  in  acute  affections  accompanied 
by  active  excitement.  In  wasting  and  prostrating  ailments,  on 
the  other  hand,  the  skin  feels  very  relaxed  and  soft ;  and  in  those 
producing  rapid  emaciation,  it  is  inelastic  and  lies  in  folds. 

Pulse. — The  study  of  the  pulse  has  come  down  to  us  with  the 
sanction  of  centuries ;  and  to  feel  the  beat  at  the  wrist  is  still,  in 
the  opinion  of  many,  as  indispensable  to  the  understanding  of  a 

3 


34  MEDICAL    DIAGNOSIS. 

case  as  it  was  tlioiitrht  td  be  bv  the  Arabs  and  in  tlic  ^Middle 
Ages.  Yet  tlie  advanee  of  scienee  has  shaken  the  belief  in  tlie 
paramount  inipoitanee  of  the  pulse.  It  has  shown  that,  althoutih 
a  most  valuable  means  of  information,  it  is  not  exelusively  to  be 
relied  upon,  and  has  proved  the  many  divisions  and  refinements 
of  the  physicians  of  by-gone  days — who  endeavored  by  the  pulse 
to  judge  of  every  conceivable  morbid  condition — to  be  practically 
useless.  Indeed,  were  even  all  tlieir  distinctions  founded  in  fact, 
we  have  now  better  ways  of  judging  of  many  lesions  than  by 
feeling  the  radial  artery. 

The  pulse  enlightens  us  on  the  action  of  the  heart,  and  on  some- 
thing more, — on  the  state  of  the  artery  itself  and  of  the  blood. 
In  a  healthy  adult  a  beat  of  some  resistance  is  felt,  recurring  from 
sixty-five  to  seventy-five  times  in  a  minute.  It  becomes  slower 
with  advancing  years,  though  it  may  rise  in  the  very  aged.  The 
pulse  of  infancy  is  from  one  hundred  and  ten  to  one  hundi'cd  and 
twentv  ;  that  of  a  child  three  years  old,  from  ninety  to  ninety-five. 
"Warmth  quickens  the  pulse ;  so  do  rajiid  breathing,  forced  expira- 
tion, and  the  process  of  digestion.  In  the  recumbent  position  and 
during  sleep  it  ialls. 

At  the  bedside  we  study  in  the  pulse  its  frequency,  its  rhythm, 
its  volume  and  strength,  and  its  resistance. 

Increased  frequency  of  the  pulse  denotes  increased  frequency 
of  the  heart's  action,  and  arises  from  any  cause  which  excites  the 
heart.  Hence  exercise,  rapid  breathing,  mental  emotion,  or  rest- 
lessness will  occasion  the  number  of  beats  to  exceed  the  average 
of  health  as  readily  as  fevers  or  acute  inflammatory  diseases.  In 
great  debility,  to^,  the  pulse  rises ;  and  the  more  depressed  the 
vital  condition,  the  higher  the  pulse  becomes.  The  heart  may 
thus  quicken  from  so  many  and  such  varied  causes,  acting  tempo- 
rarilv  or  permanently,  that  increased  frequency  of  i)ulse,  taken  by 
itself,  has  no  significant  diagnostic  meaning. 

A  slow  pulse,  too,  happens  in  many  different  states, — in  cold,  in 
exposure  to  wet,  in  icterus.  It  is  also  produced  by  an  intense  and 
prostrating  shock,  or  is  found  coexisting  Avith  pressure  on  the  brain. 
In  some  persons  the  pulse  is  naturally  very  slow. 

The  rhythm  of  the  pulse  is  often  perverted.  Instead  of  the 
beats  following  one  another  in  regular  succession,  they  are  unequal, 
or  one  or  two  intermit.     An  irregular  pulse  occurs  from  digestive 


EXAMINATION   OF    PATIENTS,  ETC.  3o 

disorder,  from  gout,  from  lithffimia,  from  the  excessive  use  of 
tobacco,  or  from  debility  and  nervous  exhaustion ;  but  it  is  fre- 
quently the  indication  of  a  cerebral  or  cardiac  lesion.-  It  is  some- 
times a  difficult  beat  to  count ;  and  we  must  be  careful  not  to 
regard  at  once  a  pulse  as  irregular  because  it  appears  to  intermit. 
The  seeming  irregularity  may  be  caused  by  the  fingers  slipping 
from  the  artery,  ^vhich  they  are  very  apt  to  do  after  they  have 
been  on  the  vessel  for  some  time. 

The  volume  and  strength  of  the  pulse  are  of  much  more  im- 
portance than  either  its  rhythm  or  its  frequency.  Volume  and 
strength  are  often  associated,  and  are  much  alike ;  but  they  are 
not  identical.  When  the  beat  of  the  artery  is  large,  we  call  it 
a  full  pulse.  This  is  owing  to  the  distention  of  the  vessel  with 
blood, — its  complete  expansion  with  every  beat  of  the  heart.  A 
full  pulse  is,  therefore,  tJie  pulse  of  plethora ;  the  pulse  of  the 
young  and  robust  in  health,  or  in  inflammatory  diseases  ;  the  pulse 
in  the  early  stages  of  fevers,  or  in  obstruction  of  the  capillaries. 
It  is  usually  a  pulse  of  power,  just  as  its  opposite,  a  small  pulse, 
is  usually  the  pulse  of  debility.  Yet  a  full  pulse  may  be  pro- 
duced by  the  distention  of  an  artery  which  has  lost  its  tone,  and 
which  the  finger  easily  compresses.  Such  a  pulse,  the  "  gaseous 
pulse,"  denotes  exhaustion,  and  proves  that  a  full  pulse  and  a 
strong  pulse  are  not  always  synonymous.  Indeed,  into  the  idea 
of  strength  something  more  than  mere  fulness  enters.  A  strong 
pulse  is  a  natural  pulse  heightened  in  all  its  characters.  It  has 
more  fulness,  but,  in  addition,  more  impulse,  and  less  compressi- 
bility, than  an  ordinary  pulse.  A  strong  pulse,  therefore,  indicates 
activity  of  the  contraction  of  the  heart,  and  a  normal,  perhaps 
increased,  tonicity  of  the  arterial  coats.  It  is  found  in  active  in- 
flammations ;  also  in  hypertrophy  of  the  heart.  Its  opposite,  a 
weak  pulse,  betokens  want  of  force,  often  want  of  healthy  blood. 
It  is  generally  small  as  well  as  weak.  Yet  as  the  full  pulse  is 
not  always  strong,  neither  is  the  small  pulse  always  weak.  The 
small,  choked  pulse  of  peritoneal  inflammation  may  be  fine  and 
wiry,  but  it  is  not  a  weak  pulse. 

The  resistance  or  tension  of  the  pulse  is  another  valuable  guide 
in  the  appreciation  of  morbid  action.  Is  the  pulse  hard  and 
resisting  ?  is  it  soft  and  compressible  ?  are  questions  on  the  solu- 
tion of  which  the  application  of  remedies  may  hang.     A  hard, 


36  MEDICAL    DIAGNOSIS. 

tense  pulse  denotes  increased  contractility  of  the  arteries,  and 
high-wrought  power.  Be  the  beat  full  or  small,  slow  or  frequent, 
it  tells  us  that  the  blood  is  being  driven  with  force  along  the 
arterial  system.  But  it  also  tells  us  that  the  irritation  has  im- 
plicated the  coats  of  the  arteries  themselves,  as  their  extreme 
resistance  to  the  finger  plainly  shows.  A  tense  pulse  is  met  with 
in  active,  violent  inflammations,  and  sometimes,  though  not  often, 
in  states  of  extreme  and  continued  excitement  without  inflamma- 
tion. It  is  almost  needless  to  add  that  changes  in  the  coats  of  the 
arteries  may  also  be  a  cause  of  a  hard  and  resistant  beat.  AVhere 
no  local  alterations  are  present,  and  where  no  acute  sym^jtoms  ex- 
plain the  sympathetic  disturbance  of  the  heart  and  arterial  system, 
a  tense  pulse  will  be  commonly  found  associated  with  hypertrophy 
of  the  left  ventricle. 

The  opposite  of  the  hard  pulse  is  the  soft  or  compressible  pulse. 
This  implies  deficient  impulsion,  and  loss  of  tone  in  the  vessel ; 
it  is  the  pulse  of  low  fevers  and  debility.  But  it  is  also,  Avhen 
following  a  tense  state  of  the  artery,  the  ])ulse  which  denotes 
returning  health,  and  imminent  danger  passed. 

Such  are  the  meanings  attached  to  the  various  characters  of  the 
pulse.  Yet  they  do  not  often  present  themselves  thus  isolated. 
The  following  are  usually  combined,  and  bear  this  explanation  : 

A  hard,  full,  frequent  pulse  occurs  in  active  inflammations,  and 
in  most  of  the  acute  diseases  of  robust  persons. 

A  hard  pulse,  full  or  small,  bounding  or  not,  if  unconnected 
with  acute  symptoms,  leads  to  the  suspicion  of  cardiac  disease,  or 
of  an  afl^ection  of  the  artery  itself. 

A  tense,  contracted,  and  frequent  pulse  is  met  with  in  a  large 
group  of  inflammations  below  the  diaphragm,  as  in  enteritis,  peri- 
tonitis, gastritis. 

A  frequent  pulse,  full  or  small,  but  not  tense,  is  the  pulse  of 
most  idiopathic  fevers. 

A  very  frequent  pulse,  but  very  feeble  and  compressible,  is  the 
pulse  of  marked  debility,  of  prostration,  of  collapse. 

A  pulse  frequent,  and  changeable  in  its  rhythm,  is  produced, 
for  the  most  part,  by  disease  either  of  the  heart  or  of  the  brain, 
or  by  perverted  innervation  in  connection  with  gastric  disorders. 

The  appreciation  of  these  difi^erent  kinds  of  pulses  requires  con- 
siderable practice.     But  even  this  scarcely  teaches  us  to  estimate 


EXAMINATION    OF   PATIENTS,  ETC.  3* 

the  exact  degree  of  the  alteration  of  the  beat,  certainly  not  with 
sufficient  distinctness  to  convey  to  others  an  accurate  idea,  or  even 
to  be  able  ourselves  to  compare  one  observation  with  another.  To 
attain  these  desirable  results,  instruments  have  been  sought  for  by 
means  of  which  the  pulse  can  be  examined  with  precision,  its  finer 
shades  of  difference  recognized,  and  its  movements  recorded.  The 
best  instrument  as  yet  invented  is  the  sphygmograph  of  Marey, 


Fig.  1. 


The  sphygmograph  attached  to  the  wrist.    Its  tracings  are  shown  by  the  white  lines  on  the  black 

background. 


which  registers  with  correctness  not  only  the  frequency  and  regu- 
larity but  the  form  of  the  pulse- wave,  and  may  be  also  applied  to 
the  study  of  the  cardiac  impulse  and  of  pulsatile  tumors.  Slight 
irregularities  which  wholly  escape  the  finger  are,  through  its  aid, 
discerned  with  facility,  and  we  tell  at  once  in  how  far  these  irregu- 
larities belong  to  one  beat  or  to  a  succession  of  beats.  Double 
beats  with  each  contraction  of  the  heart,  too,  not  appreciable  to 
the  hand,  are  easily  detected.  This,  the  "  dicrotic"  pulse,  or  the 
pulsus  biferiens  of  the  older  authors,  is  most  commonly  met  with 
in  fevers  of  a  typhoid  form,  and  preceding  or  during  the  continu- 
ance of  hemorrhages.  Yet  the  phenomenon  of  dicrotism  may  be 
stated  to  be  really  a  physiological  one,  since  the  sphygmograph 
proves  it  to  exist  in  almost  every  person.  The  rebound  is  chiefly 
due  to  the  oscillation  of  the  column  of  blood  in  the  arteries,  and 
is  very  much  influenced  by  their  elasticity.  It  is  rarely  suf- 
ficient to  be  determined  by  the  touch,  except  when  the  arterial 
tension  or  contractility  is  lessened  and  the  elasticity  of  the  tubes 
increased,  as  happens  in  the  disorders  in  which  the  dicrotic  pulse 
is  encountered.  In  old*  persons,  in  whom  the  coats  of  the  arteries 
are  inelastic,  dicrotism  is  but  feebly  marked.  A  rapid  circulation 
renders  the  pulse  more  obviously  dicrotic.     The  rebound  may 


38  MEDICAL    DIAGNOSIS. 

occur  during  the  svstule  or  the  diastole  of  the  vessel  ;  and  instead 
of  one,  there  may  be  four  or  five  of  the  secondary  pulsations. 

When  we  apply  the  sphvgraograph  for  clinical  purposes,  we 
study  ehieHy  in  its  tracing  the  line  of  ascent,  the  summit,  and  the 
line  of  descent.  Each  pulsation  is  composed  of  these  three  parts. 
The  liae  of  ascent,  the  upstroke,  tells  us  the  manner  in  wliich  the 
blood  enters  the  vessels.  The  more  rapid  the  flow,  and  the  more 
quickly  the  artery  distends,  the  more  vertical  the  line.  The  force, 
too,  is  indicated  by  this  line,  or  rather  by  its  height :  hence  when 
the  muscles  of  the  heart  contract  powerfully,  either  from  enlarge- 
ment or  from  overaction,  the  line  is  both  vertical  and  high.  Yet 
the  strength  of  the  ventricular  contraction  is  far  from  being  the 
only  cause  influencing  the  amplitude  of  the  tracing.  Indeed,  as 
we  may  note  in  old  persons,  a  large  volume  of  the  artery  gives 
considerable  height  to  the  lines  of  ascent ;  so  does  a  long  interval 
between  the  pulsations,  or  the  obstruction  of  the  vessel  below 
the  point  where  the  observation  is  made.  A  state  of  feeble  ten- 
sion in  the  capillary  system  has  the  same  effect ;  -whereas  when 
the  passage  in  the  ultimate  ramification  of  the  vascular  system  is 
difficult,  the  lever  descends  slowly  by  a  line  convex  upward,  and 
is  soon  again  raised  by  the  next  pulsation.  When  the  contraction 
of  the  heart  is  feeble,  the  line  of  ascent  is  not  vertical  or  high. 

The  line  joining  the  summit  of  a  series  of  pulsations,  or  the 
maxima  of  tension,  is  generally  a  straight  line  ;  a  similar  imagi- 
nary line  connecting  the  bases,  or  the  minima,  is  apt  to  run  par- 
allel to  it ;  but  irregularity  of  pulsation  leads  to  irregular  lines, 
and  the  lower  line  may  be  irregular  while  the  upper  is  straight. 

The  summit  of  the  pulsation  informs  us  of  the  time  during  which 
the  entrance  of  blood  balances  the  onward  flow.  A  pointed,  dis- 
tinct summit-wave  belongs  to  vigorous  contraction  of  the  heart- 
muscle.  The  summit  may  be  a  horizontal  line  of  some  length, 
and  an  extended  plateau  of  the  kind  is  apt  to  be  met  with  in  in- 
duration or  ossification  of  the  arteries.  In  some  instances  we  find 
a  little  hooked  point  preceding  the  usually  transverse  mark  of  the 
summit.  This  occurs  by  the  rapid  movement  of  the  lever,  and 
is  a  sio;n  of  reffurcritation  through  the  aortic  valves.  In  aortic 
narrowing;  of  marked  degree  the  summit-wave  is  indistinct  or 
absent ;  the  line  of  ascent  is  oblique  and  gradual,  and  may  show 
a  break. 


EXAMINATION    OF    PATIENTS,  ETC.  39 

The  line  of  descent  follows  the  closure  of  the  semilunar  valves. 
It  is  sometimes  purely  oblique,  and  the  more  rapidly  the  pressure 
is  lessened  in  the  arterial  system,  the  more  oblique  is  the  line. 
It  often  shows  a  series  of  undulations,  which  give  rise  to  the 
dicrotism  in  the  pulse  which  has  been  above  mentioned.  The  first 
of  the  secondary  waves  is  called  the  tidal  wave ;  the  marked  sub- 
sequent wave  is  often  specially  called  the  dicrotism,  or  the  great 
secondary  wave.  The  tidal  wave  is  large,  but  the  dicrotism  badly 
marked,  in  atheroma.  In  mitral  narrowing,  the  line  of  descent  is 
long,  but  broken  by  small  pulsations. 

These  points  must  all  be  attended  to  in  examining  sphygmo- 
graphic  tracings;  but,  unfortunately,  the  mode  of  adjusting  the 
instrument,  and  of  proportioning  the  pressure  of  the  spring,  has 
something  to  do  with  the  kind  of  delineation  obtained.  To  secure 
greater  accuracy,  Sanderson  fixed  the  centre  button  at  a  definite 
pressure,  thus  insuring  an  arrangement  very  useful  for  purposes 
of  comparison  ;  and  Mahomed*  added  several  serviceable  contri- 
vances, one  of  the  chief  of  which  is  the  causing  of  the  amount 
of  pressure  employed  to  be  accurately  registered  upon  a  dial. 
Still  another  modification,  which,  however,  really  makes  use  of  a 
different  principle,  the  displacing  power  of  the  artery  rather  than 
its  lifting  power,  has  been  made  by  Holden.f  The  movement 
thus  obtained  is  from  side  to  side.  Among  recent  sphygmo- 
graphs,  one  making  extremely  fine  tracings  is  that  of  Pond.|  A 
rubber  diaphragm  takes  the  place  of  the  spring  of  other  sphyg- 
mographs,  and  is  fixed  to  the  artery  by  means  of  a  holder.  A 
delicate  needle  makes  the  tracing. 

To  show  the  tracing  distinctly,  smoked  glass  or  mica,  or  paper 
smoked  over  a  lamp  or  by  burning  camphor,  has  been  of  late 
much  used.  Manifold,  too,  have  been  the  suggestions  to  obtain 
the  steadiest  application  of  the  instrument  to  the  forearm  and 
the  greatest  development  of  the  trace.  Lorain  §  has  proved  that 
raising  the  arm  to  a  vertical  position  gives  a  much  more  ample 
trace.     Still,  with  all  the  careful  work  on  the  subject,  and  all  the 

*  Medical  Times  and  Gazette,  Jan.  1872. 
f  The  Sphygmograph ,  Phila.,  1874. 

X  Pamphlet  on  Improved  Sphygmograph.     See  also  Med.   and  Surg.  Ee- 
porter,  June,  1878;  and  Archives  of  Medicine,  vol.  i.,  New  York,  1879. 
I  Le  Pouls,  Paris,  1870. 


40  MEDICAL    DIAGNOSIS. 

perfection  of  tlie  instrument,  its  precise  value  for  clinical  research 
is  undetermined.  I  think  it  of  much  more  avail  in  investigations 
on  the'  exact  action  of  medicines — where,  indeed,  it  is  of  great 
value — than  in  aiding  us  materially  in  questions  of  diagnosis  or 
in  decisions  on  treatment.  At  all  events,  I  do  not  think  that  it 
supersedes  the  older  and  more  usual  means  of  research.  Perhaps 
records  of  pulse-traces  in  Avhich  the  amount  of  pressure  has  been 
carefully  noted  will  enable  us  to  judge  more  and  more  accurately, 
much  more  accurately  than  we  do  now,  of  the  state  of  the  cardiac 
muscles  in  disease. 

Tongue. — When  a  patient  is  told  to  put  out  his  tongue,  it  is 
not  to  see  whether  this  organ  is  the  seat  of  disease,  but  because 
experience  has  taught  that  the  tongue  is  a  mirror,  more  or  less 
perfect,  of  the  condition  of  the  digestive  functions,  and  that  it 
reflects  the  complexion  of  the  nervous  power  and  of  the  blood, 
and  the  state  of  the  secretions.  To  judge  of  these  varied  circum- 
stances, we  have  to  examine  the  tongue  in  regard  to  its  move- 
ments, its  volume,  its  dryness  or  its  humidity,  its  color,  and  its 
coating. 

The  onovemenfs  of  the  tongue  are  impeded  and  tremulous  in 
all  conditions  of  the  system  attended  with  exhaustion.  It  is  pro- 
truded slowly  and  with  difficulty  in  fevers  of  a  low  type,  and  in 
nervous  disorders  which  are  accompanied  by  marked  debility. 
The  action  of  the  muscles  is  seriously  impaired  in  paralysis. 
In  hemiplegia  one  side  is  crippled,  and  the  tongue  turns  toward 
one  of  the  corners  of  the  mouth.  \Vhen  imperfect  articulation 
is  associated  with  difficulty  in  moving  the  organ,  it  commonly 
announces  a  serious  cerebral  lesion. 

The  volume  of  the  tongue  is  changed  by  its  own  diseases ;  more 
rarely  by  the  condition  of  the  system  at  large,  or  by  disturbances 
of  the  abdominal  viscera.  Yet  a  swollen  or  a  broad  and  flabby 
tongue,  on  the  sides  of  Avhich  the  teeth  leave  their  marks,  is  some- 
times found  in  chronic  ailments  of  the  digestive  organs,  and  as 
the  result  of  the  action  of  mercury,  and  of  certain  poisons.  It  is 
further  observed  in  some  affections  of  the  brain,  or  as  a  conse- 
quence of  the  disturbed  circulation  attending  diseases  of  the  heart, 
and  in  distempers,  like  the  plague,  typhus,  or  scurvy,  in  which 
the  blood  is  much  altered.  The  tongue  is  sometimes  observed  to 
be  swollen  on  one  side  only  in  consequence  of  catarrhal  inflam- 


EXAMINATION   OF   PATIENTS,  ETC.  41 

mation.     This  liemiglossitis  affects  the  left  side,  and  is  supposed 
to  be  really  of  neurotic  origin.* 

Dryness  of  the  tongue  indicates  deficient  salivary  secretion. 
In  acute  visceral  inflammations,  and  still  more  frequently  in 
febrile  states,  especially  in  the  exanthemata  and  in  typhoid  fever, 
the  tongue  is  dry;  it  may  be  so  dry  as  to  cause  the* papillae  to 
become  prominent  and  the  whole  organ  to  appear  roughened. 
This  condition  is  one  which,  in  acute  diseases,  is  always  to  be 
dreaded,  especially  if  the  tongue  be,  in  addition,  of  a  dark  color, 
glazy,  or  furred  or  fissured ;  for  it  is  then  a  proof  not  only  of 
generally  arrested  secretions,  but  also  of  depraved  blood  and  of 
ebbing  life-force.  Yet  a  fissured  tongue  is  not,  by  itself,  indic- 
ative of  great  and  imminent  danger ;  it  may  occur  in  chronic 
affections  of  the  liver,  or  in  chronic  inflammation  of  the  intes- 
tines ;  and  in  some  persons  it  is  congenital.  In  estimating  dry- 
ness of  the  tongue  we  must  not  overlook  the  fact  that  this  may 
happen  from  persistent  openness  of  the  mouth,  as  during  sleep, 
from  ol^struction  of  the  nasal  passages,  or  from  coma.  Among 
chronic  diseases  the  tongue  is  most  apt  to  be  found  dry  in  dia- 
betes. A  dry,  incrusted,  brown  tongue  is  due  to  a  continuous 
crust  on  and  between  the  papillae,  which  is  filled  with  parasitic 
growths.  It  occurs  in  states  of  prostration  with  lowering  of 
nutrition  and  tendency  to  sinking.  A  dry  tongue  is  never  a 
favorable  sign.  A  recent  writer  has  calculated  that  it  is  present 
in  about  fifty  per  cent,  of  fatal  cases  ;  more  than  any  other  it  fore- 
tells death. t  The  opposite  of  dryness,  humidity,  is,  unless  exces- 
sive, a  favorable  sign.  It  is  extremely  so  if  it  succeed  to  dryness, 
because  it  is  a  proof  that  the  secretions  are  being  re-established. 

The  color  of  the  tongue  is  subject  to  many  variations.  It  is  re- 
markably pale  whenever  the  blood  is  watery  and  deficient  in  red 
globules.  It  is  exceedingly  red  and  shining  in  the  exanthemata, 
especially  in  scarlet  fever.  The  tongue  is  also  very  red  if  inflam- 
mation have  attacked  its  substance,  or  the  fauces,  or  the  pharynx. 
It  is  bluish  and  livid  when  there  is  an  obstruction  to  the  flow 
of  the  venous  blood  or  deficient  aeration,  as  in  some  structural 
diseases  of  the  heart  and  in  dangerous  cases  of  bronchitis  or 


*  Dyce  Duckworth,  Liverpool  IMed.-Chir.  Journ.,  July,  1883. 

f  Dickinson,  The  Tongue  as  an  Indication  in  Disease,  London,  1888. 


42  .MEDICAL    DIAGNOSIS. 

pneumonia.  A  red,  smooth  tongue  is  a  sign  of  failing  nutri- 
tion. 

As  important  as  the  coh)r  of  the  organ  are  the  e()h)r  and  form 
of  its  coating.  In  heahh  the  tongue  has  hardly  a  diseernible 
lining;  disease  quiekly  gives  it  one.  In  inflammation  of  the 
respiratory-  textures,  at  tlie  beginning  of  fevers,  in  disorders  of 
large  portions  of  the  abdominal  mucous  tract,  the  ei)ithelium 
accumulates,  and  the  tongue  has  a  loaded,  whitish  appearance, 
due  to  excess  of  white  epithelium  on  the  papillte  with  the  inter- 
vals also  more  or  less  filled  up.  The  coat  is  apt  to  be  yellowish 
in  disturbances  of  the  liver,  and  of  a  brown  or  very  dark  hue 
when  the  blood  is  contaminated.  But  we  must  be  sure,  in  draw- 
ing our  inferences,  that  the  abnormal  aspect  is  not  due  to  the  food 
partaken  of,  or  to  medicine.  Its  color  is  also  modified  by  the 
character  of  the  occupation.  Thus,  as  Chambers  tells  us,  there 
is  a  smooth,  orange-tinted  coating  on  the  tongues  of  tea-tasters. 
A  local  cause  sometimes  gives  rise  to  a  thick,  opaque  coat.  For 
instance,  decayed  teeth  may  produce  a  yellow  sheathing  on  one 
side.  Affections  of  the  fauces  also  occasion  a  deep-yelloAV  hue. 
Again,  there  are  many  healthy  persons  aaIio  wake  up  every  morn- 
ing with  their  tongues  covered,  more  especially  at  the  back,  with 
a  heavy  coating,  which  wears  off  after  a  meal. 

In  some  diseases  the  epithelium,  which  is  either  formed  in  ex- 
cessive quantities  or  not  thrown  off,  collects  between  the  papillse, 
leaving  them  uncovered  and  prominent.  This  is  especially  noticed 
in  scrofulous  children.  When  the  epithelium  is  sticky  and  ad- 
herent, it  Avinds  itself  chiefly  around  the  filiform  papillae,  elon- 
gating them  and  giving  to  the  surface  of  the  organ  a  furred  ap- 
pearance. Although  this  kind  of  tongue,  as  almost  every  other 
variety,  is  met  with  now  and  then  in  persons  who  are  not  ill,  yet 
it  may  generally  be  looked  upon  as  denoting  disease.  It  occurs 
sometimes  in  chronic  diseases  of  the  abdominal  viscera,  but  nnuh 
oftener  in  grave  acute  maladies.  The  tongue,  on  the  other  hand, 
may  be  bare  of  its  epithelium  or  imperfectly  covered  with  it. 
We  meet  with  this  in  certain  instances  of  scurvy,  or  in  cases  of 
chronic  diarrhoea  and  dysentery  with  great  prostration,  in  A\hich 
the  tongue  is  often  found  to  be  red,  smooth,  and  dry,  or  in  attend- 
ance on  cachexias,  as  the  malarial.  Again,  a  denuded  tongue  is 
common  in  scarlet  fever,  and  not  infrequent  in  typhoid  fever.     In 


EXAMIXATIOX    OF    PATIENTS,  ETC.  43 

scarlet  fever  it  has  a  strawberry  look.  Tliis  is  sometimes  also 
seen  in  pneumonia. 

To  sum  lip,  before  leaving  the  subject,  the  manifestations 
afforded  by  the  tongue  which  are  indicative  of  danger.  They  are, 
tremulous  action  ;  dryness ;  a  livid  color ;  a  very  red,  sliining, 
or  raw  aspect ;  a  heavy  coating  of  a  dark  or  black  hue.  Any 
change  from  these  to  a  more  natural  look  bears  a  favorable 
interpretation. 

The  state  of  the  digestion  and  the  character  of  tlie  discharges 
have  so  close  a  connection  with  the  nutrition  of  the  body  that 
they  become  important  general  symptoms.  But,  for  the  sake  of 
convenience,  their  value  will  be  incpiired  into  while  discussing 
tlie  diseases  in  the  recognition  of  which  they  occupy  the  foremost 
place.     A  few  words  here,  however,  on  the  sensations  of  patients. 

Sensations  of  Patients. — Sick  persons  are  subject  to  many 
disagreeable  feelings.  They  complain  of  chills,  of  heat,  of  lan- 
guor, of  restlessness,  and  of  uneasiness ;  but  their  most  constant 
complaint  is  of  pain.  Now,  pain  may  be  of  various  kinds ;  it 
may  be  dull  or  gnawing ;  it  may  be  acute  and  lancinating.  In 
its  duration  it  may  be  permanent  or  remitting.  A  dull  pain  is 
generally  persistent.  It  is  most  often  present  in  congestions,  in 
subacute  and  chronic  inflammations,  and  where  gradual  changes 
of  tissues  are  taking  place.  It  is  the  pain  of  chronic  rheumatism, 
and  shades  oif  into  the  innumerable  aches  of  this  malady.  The 
only  acute  aifections  in  which  it  is  apt  to  exist  are  inflammations 
of  the  parenchymatous  viscera  and  of  mucous  membranes. 

Acute  pain  is  in  every  respect  the  reverse  of  dull  pain.  It  is 
usually  remittent,  and  not  so  fixed  to  one  spot.  It  is  met  with  in 
spasmodic  affections,  in  neuralgia,  and,  with  extremely  sharp  and 
lancinating  pangs,  in  malignant  disease. 

Pain  varies  much  in  intensity ;  it  is  sometimes  so  extreme  as 
to  cause  death.  We  have  to  judge  of  its  severity  partly  on  the 
testimony  of  the  sufferer,  partly  by  the  countenance,  and  partly 
by  the  attending  functional  disturbances.  The  latter  are  not  to 
be  overlooked,  for  they  enable  us,  to  some  extent,  to  appreciate 
whether  the  torments  are  as  great  as  they  are  represented  to  be. 

The  seat  to  which  the  pain  is  referred  is  far  from  being  always 
the  seat  of  the  disease.  A  calculus  in  the  bladder  may  produce 
dragging  sensations  extending  down  the  thighs ;  inflammation  of 


44  MEDICAL   DIAGNOSIS. 

the  hip-joint  gives  rise  to  pain  in  tlio  knee ;  disordei's  of  the  liver 
occasiou  pain  in  the  right  shonlder.  Pain  felt  at  some  part  remote 
from  that  affected  is  either  tmnsmitted  in  the  course  of  a  nerve 
involved,  or  is  sympathetic. 

The  same  abnormal  action  docs  not  always  create  the  same 
kind  of  pain.  Inflammation,  for  instance,  causes  different  pain 
as  it  involves  different  structures  :  the  pain  from  an  inflamed 
pleura  is  not  the  same  as  that  from  an  inflamed  muscle.  Speak- 
ing generally,  the  tissues  themselves  seem  to  determine  the  form 
of  pain  more  certainly  than  does  the  precise  character  of  the 
morbid  process.  Thus,  pain  in  diseases  of  the  periosteum  and 
bones,  no  matter  what  may  be  the  exact  nature  of  the  malady, 
is  mostly  boring  and  constant ;  in  the  serous  membranes,  sharp  ; 
in  the  mucous  membranes,  dull ;  and  in  the  skin,  burning  or 
itching. 

Pain  produced  by  pressure  is  called  tenderness.  It  indicates 
increased  sensibility,  and  is  most  constantly  associated  with  inflam- 
mation. Yet  tenderness  may  be  present  without  inflammation ; 
the  tenderness,  for  example,  of  the  skin  in  hysteria.  Commonly 
it  is  combined  with  pain  occurring  independently  of  pressure  ;  but 
a  part  may  be  tender  and  not  painful. 

Temperature  of  the  Body. — There  is  one  more  symptom 
of  general  significance  which  must  be  mentioned, — namely,  that 
connected  with  the  heat  of  the  body.  The  thermometry  of  dis- 
ease has,  indeed,  become  indispensable  in  the  recognition  of  morbid 
states.  The  thermometer  used  for  clinical  purposes  should  be 
very  sensitive,  and  requires  to  be  from  time  to  time  compared 
with  a  standard  one,  and  verified.  It  may  be  straight,  or  curved. 
The  scale,  extending  from  about  85°  to  115°  Fahr.,  ought  to  be 
uniformly  graduated ;  it  should  be  divided  so  as  to  exhibit  fifths 
of  a  degree.  More  useful  than  the  ordinary  curved  instrument 
is  the  clinical  self-registering  thermometer  (Fig.  3).  A  straight 
thermometer,  generally  short,  for  convenience'  sake,  it  has  the 
mercury  detached  from  the  column.  This  detached  part,  or  the 
index,  is  set  by  bringing  it  down  below  the  lines  of  the  scale  by 
a  rapid  swing  of  the  arm.  After  the  thermometer  has  been  in 
position  for  the  required  period,  it  is  removed,  and  the  end  of  the 
index  farthest  from  the  bulb  records  the  maximum  temperature. 
A  magnifying  front  allows  the  degrees  to  be  easily  read.    Metallic 


EXAMINATION   OF   PATIENTS,  ETC. 


45 


Flq.  2. 


Fig.  3. 


Fig.  4.  Fio.  5. 


80-: 


Thermometer  for  clinical  purposes. 
Nearly  natural  size. 


Seguin's   Sur- 
face Tlier-    The  Thermo- 
mouieter.  scope. 


Self-Eegistering  Thermom- 
etei',  showing  the  index 
marking  99°  shortly  after 
an  observation. 


4G  MEDICAL   DIAGNOSIS. 

tlierniouictors  are  neither  so  cleanly  nor  so  trustworthy  as  those 
made  of,  glass. 

As  surfoce  thermometers  for  loealized  thernioiiietry  various  in- 
struments have  been  suggested.  I  habitually  employ  one  whieh 
has  the  mercury  in  a  fine  coil  at  the  expanded  extremity,  and 
which  is  self- registering.  The  ordinary  self-registering  clinical 
thermometer  may  be  made  use  of,  with  the  bulb  fitted  into  a 
piece  of  cork.  Whatever  instrument  be  resorted  to,  we  should 
first  obtain  the  heat  of  a  corresponding  or  analogous  well  part, 
and  then  leave  the  bulb  for  five  minutes  on  the  suspected  abnor- 
mal structure.  Better  still  is  it  to  a]i]ily  two  instruments  at  the 
same  time ;  one  on  the  sound,  the  other  on  the  unsound  side.  In 
all  observations  the  heat  of  the  body,  as  ascertained  in  the  axilla, 
should  also  be  noted. 

Still  another  instrument,  designed  chiefly  to  show  the  activity 
of  the  heat-making  function,  is  the  thermoscope,  invented  by 
Seguin.  Fig.  5  explains  it.  The  bulb  is  heated,  and  the  open 
end  of  the  tube  is  then  plunged  into  cold  water.  The  drop  or 
two  which  run  up  to  near  the  bulb  become  the  index ;  in  five  or 
ten  seconds  the  index  will  attain  the  maximum  height  or  fall. 
A  mobile  scale  is  attached  to  the  stem,  and  its  lowest  figure  is  to 
be  put  on  a  level  with  the  head  of  the  water-index.*  Thermo- 
electric apparatus  have  also  been  employed  for  surface  thermom- 
etry, and  certainly  give  very  accurate  results.  But,  with  per- 
haps the  exception  of  the  instrument  of  Lombard,!  they  are  not 
sufficiently  portable  or  easily  enough  managed  for  general  use. 

The  surface  temperature  is,  as  a  rule,  lower  by  upwards  of  one 
or  by  several  degrees  than  the  general  temperature.  We  find  it 
so  on  the  chest,  on  the  abdomen,  and  on  the  head.  The  tempera- 
ture, too,  is  not  on  corresponding  sides  entirely  the  same,  at  least 
not  on  the  head.  There  is  almost  always  a  slight  inequality  in 
the  temperature  of  the  two  sides  of  the  head  ;  Gray|  demonstrates 
that  when  at  rest  the  temperature  of  the  left  hemisphere  is  the 
higher,  which  accords  with  Broca's  statement.  And  the  observa- 
tions of  Amidon§  have  shown  that  excessive  use  of  a  group  of 


*  Paper  read  before  the  New  York  State  Medical  Society,  1875. 
t  "  On  the  llegional  Temperature  of  the  Head,"  London,  1879. 
X  Chicago  Journal  of  Mental  and  Nervous  Diseases,  1879. 
§  New  York  Archives  of  Medicine,  April,  1880. 


EXAMINATION    OF    PATIENTS,  ETC.  47 

muscles  may  generate  heat  in  the  cortical  region  presiding  over 
them,  sufficient  to  manifest  itself  to  surface  thermometers  placed 
on  the  scalp.  The  mean  temperature  of  a  healthy  man's  head  is 
fixed  by  Maragliano  and  Seppili,  as  the  result  of  many  observa- 
tions, at  36.13°  Cent.  (97.03°  Fahr.)  for  the  left  side  of  the  head, 
and  36.08°  Cent.  (96.9°  Fahr.)  for  the  right.*  These  tempera- 
tures are  much  higher  than  those  given  by  Broca  and  Gray,  which 
is  accounted  for  by  their  having  been  taken  in  summer.  Broca 
places  the  frontal  region  on  the  left  side  of  the  head  at  35.43°  Cent. 
(95.79°  Fahr.),  on  the  right  at  35.22°  Cent.  (95.39°  Fahr.); 
Gray's  figures  are  somewhat  lower.  The  parietal  region  on  the 
right  side  is  fixed  by  Broca  at  92.8°  ;  by  Gray  at  93.6°  on  the 
right,  and  94.4°  on  the  left ;  the  vertical  by  Gray  at  91.7°,  and 
the  occipital  at  91.9°  ;  the  whole  side  of  the  head  by  Broca  at 
about  93°  ;  the  entire  head  at  places  remote  from  these  points  at 
93.5°  by  Gray.f 

As  regards  the  abdomen,  Peter  |  places  the  normal  mean  of  the 
parietes  at  35.5°  Cent.  (95.9°  Fahr.),  and  the  same  observer  re- 
cords the  normal  temperature  for  the  chest-walls  at  about  36° 
Cent.  (96.8°  Fahr.).  Certain  diseases  change  the  temperature 
locally.  Thus,  in  neuralgia  the  heat  near  the  painful  points 
may  be  markedly  raised.  So,  too,  is  it  sometimes  in  some  parts 
of  the  surface  in  hysterical  women.  In  hemiplegia  the  paralyzed 
limb  may  show  a  higher  temperature  than  the  sound  one.  And 
over  spots  where  there  is  inflammation  or  where  decided  tissue- 
change  is  going  on  there  is  a  rise  in  local  temperature. 

But  to  return  to  general  thermometry.  The  clinical  thermom- 
eter may  be  put  under  the  tongue  or  in  the  rectum ;  but  the  most 
suitable  site  in  adults  is  the  axilla.  The  bulb  is  pressed  into 
the  armpit  and  kept  in  close  contact  with  the  skin  for  from  five 
to  seven  minutes.  Very  recently  thermometers  have  been  intro- 
duced requiring  but  one  minute  or  less  to  register ;  but  they  are 
too  delicate,  and  too  liable  to  be  broken,  for  ordinary  use.  The 
thermometer  may  be  conveniently  introduced  just  below  the  skin 
covering  the  edge  of  the  pectoralis  major  muscle ;  and,  to  insure 

*  Translated  in  Alienist  and  jSTeurologist.  St.  Louis,  Jan.  1880. 
flSTew  York  Archives  of  Medicine,  1879,  vol.  ii. 

J  Communication  to  the  Academic  de  Medecine,  quoted  in  Medical  Times 
and  Gazette,  Dec.  1879. 


48  MEDICAL   DIAGNOSIS. 

exactness,  the  axilla  should  be  kept  well  covered.  The  best 
posture,  as  Ringer  points  out,  is  neither  completely  on  the  back 
nor  on  the  side,  but  diagonally  on  the  right  or  the  left  side. 

In  all  eases  of  importance,  not  less  than  two  observations  should 
be  made  daily,  and,  so  far  as  possible,  every  day  at  the  same  hour. 
Between  seven  and  nine  o'clock  in  the  morning,  and  about  seven 
o'clock,  or  somewhat  earlier,  in  the  evening,  are  regarded  as  the 
most  appropriate  periods.  If  only  a  single  observation  be  taken, 
it  is  best  done  in  the  afternoon  or  evening.  Before  placing  the 
thermometer  in  position,  it  should  be  warmed  in  the  hand  or 
slightly  heated  in  water ;  and  in  every  record  of  the  temperature 
the  pulse  and  the  respirations  must  also  be  noted. 

In  temperate  climates  the  average  heat  of  the  body,  as  meas- 
ured in  the  axilla,  is  estimated  at  37°  Centigrade ;  that  of  freshly- 
voided  urine  is  about  the  same.  Expressed  in  the  scale  used  in 
this  country  and  in  England,  the  average  heat  of  sheltered  and 
internal  parts  of  the  body  may  be  stated  as  98.6°  Fahr.*  This, 
at  least,  is  the  case  in  the  axilla ;  in  the  rectum  it  is  not  quite 
1  °  higher,  and  very  steady ;  in  the  mouth  it  is  somewhat  lower. 
The  body  temperature  rises  with  the  temperature  of  the  air,  and 
fluctuates  slightly  during  the  day,  being  in  temperate  climates, 
according  to  the  most  trustworthy  observers,  lowest  between  two 
and  eight  in  the  morning,  and  highest  late  in  the  afternoon.  It  is 
heightened  by  exercise  and  reduced  by  sustained  mental  exertion, 
and  changes  even  when  we  are  at  rest.f  But,  as  a  rule,  with  the 
exception  of  very  active  exercise,  no  cause  save  disease  induces  a 
variation  of  much  more  than  1  ° ;  even  in  the  extreme  heat  of 

*  It  may  be  useful,  for  the  sake  of  comparison,  to  recall  the  fact  that  one  de- 
gree of  Fahrenheit  is  equal  to  five-ninths  of  a  degree  of  the  Centigrade  thermom- 
eter, and  four-ninths  of  a  degree  of  Eeaumur ;  and  also  that  the  freezing-point 
of  the  first  is  placed  at  32°  ;  that  of  the  others  at  zero.  To  convert  Centigrade 
into  Fahrenheit,  we  multiply  by  9  and  divide  by  5 ;  to  convert  Eeaumur,  we 
multiply  by  9  and  divide  by  4,  and  when  above  zero,  in  either  case,  add  32. 
To  convert  Fahrenheit  above  zero  into  Centigrade,  we  subtract  32,  multiply  by 
5,  and  divide  by  9. 

t  See  an  instructive  paper  by  Garrod,  on  the  jNIinor  Fluctuations  of  the  Tem- 
perature of  the  Human  Body,  Proc.  Roy.  Soc,  May,  1869  ;  an  elaborate  paper 
by  Jaeger,  Deutsches  Archiv  fiir  Klin.  Med.,  Bd.  xxix.  ;  Goodhart,  Guy's  Hos- 
pital Eeports,  3d  series,  vol.  xv.,  particularly  valuable  as  showing  the  variations 
during  the  prolonged  application  of  the  thermometer ;  and  Boileau,  Clinical 
Thermometry  in  Hot  Climates,  Lancet,  Aug.  4,  1888. 


EXAMINATION   OF   PATIENTS,  ETC.  49 

tropical  climates  the  animal  heat  does  not  surpass  99.5°.  Thus  a 
temperature  above  this,  or  more  than  a  degree  below  the  average 
stated,  when  persistent,  indicates  some  morbid  action  in  the  econ- 
omy. At  all  events,  it  does  so  in  adults ;  in  very  aged  persons  a 
temperature  of  97°  may  still  be  normal,  though  it  may  be  as  high 
as  in  infants  ;  and  we  must  bear  in  mind  that  in  children,  in  whom, 
too,  the  temperature  is  somewhat  higher  than  in  adults,  the  daily 
range  is  much  greater.  It  falls  rapidly  in  the  evening,  and  is 
very  much  influenced  by  food  and  by  crying.  Immediately  after 
birth  the  temperature  is  lowered ;  and  in  the  new-born  it  is  about 
99.8°.  It  then  falls  from  early  infancy  to  puberty.  The  rectal 
temperature  of  young  children  is  a  trifle  higher  than  that  of  adults, 
ranging  between  99°  and  99.7°.  But,  as  already  stated,  there  are 
great  variations  in  childliood.  The  maximum  is  attained  in  the 
afternoon  ;  and  the  rectal  temperaiure  may,  in  healthy  children, 
range"  from  97°  to  100°  Fahr.  During  the  first  three  or  four 
months  of  life  the  temperature,  Henoch  asserts,  has,  from  slight 
causes  of  faulty  nutrition,  a  marked  tendency  to  go  below  the 
normal.  There  may  be  a  fall  in  the  early  hours  of  the  morning 
amounting  to  between  2°  and  3°.*  A  further  point,  too,  to  be 
taken  into  account  in  those  of  all  ages  is,  that  the  temperature 
is  somewhat  influenced  by  food  and  stimulants.  And  these  are 
the  elements  which  make  deductions  from  single  observations  or 
comparatively  slight  changes  untrustworthy. 

In  ordinary  cases  the  pulse  and  temperature  rise  synchronously, 
and  every  degree  above  98°  Fahr.  corresponds  with  an  increase 
of  ten  beats  of  the  pulse.  The  fever  temperature  ranges  from 
100°  to  106°.  When  it  exceeds  this,  the  patient  may  be  looked 
upon  as  in  danger,  except  the  rise  be  due  to  malarial  fever. 
Under  these  circumstances  it  is  rapid,  occurring  in  a  person  who 
yesterday,  or  but  a  few  hours  before,  was  healthy.  In  typhoid 
fever  a  temperature  of  105°  is  a  proof  of  grave  disease.  In  some 
severe  cases  of  yellow  fever  the  heat  in  the  armpit  has  been  noted 
as  108°.t  In  pneumonia  a  temperature  above  104°  is  a  symptom 
of  a  very  serious  seizure ;  so,  too,  is  it  in  acute  rheumatism  a 


*  Finlayson,  Glasgow  Medical  Journal,  Feb.  1869,  and  Keating's  CyclopEedia 
of  the  Diseases  of  Children,  vol.  i. 

%  "Wragg,  Charleston  Medical  Journal,  vol.  x. 

4 


50  MEDICAL   DIAGNOSIS. 

symptom  either  of  danger  or  of  some  complication.  Stability  of 
temperatnre  from  morning  to  evening  is  a  good  sign ;  the  tem- 
perature remaining  the  same  from  evening  till  morning  is  a  sign 
that  the  patient  is  getting  worse.  In  convalescence  the  tempera- 
ture declines  until  it  attains  its  norm,  or  even  falls  somewhat 
below  this.  If  after  the  defervescence  the  thermometer  again 
indicate  a  decided  rise,  it  shows  a  return  of  the  malady,  or  the 
supervention  of  some  complication  or  new  disorder ;  and  the  per- 
sistence of  even  a  slight  degree  of  abnormal  heat  after  apparent 
convalescence  is  a  sign  of  imperfect  recovery,  or  of  the  existence 
of  some  lingering  secondary  complaint.  Further,  in  cases  of  low 
fevers,  the  skin,  particularly  of  the  hands  and  feet,  may  feel  cool 
at  the  same  time  that  the  instrument  in  the  axilla  marks  104°. 

Specific  forms  of  febrile  diseases  have  their  characteristic  vari- 
ations of  temperature.  In  measles,  for  instance,  the  temperature 
rises  toward  the  breaking  out  of  the  rash,  reaches  its  height  with 
the  period  of  eruption,  and  in  the  twenty-four  hours  succeeding  it 
falls  rapidly.  In  scarlet  fever  the  thermometer  marks  105°,  or 
upwards,  at  the  beginning,  and  the  heat  only  gradually  subsides. 
Typhoid  fever  has  its  characteristic  record ;  so  have  the  malarial 
fevers  theirs.  The  temperature  of  tetanus  rises  to  great  heights 
before  death. 

A  temperature  above  107°  is  almost  certain  to  be  the  forerun- 
ner of  a  fatal  issue.  But  recovery  may  take  place.  In  a  case  of 
cerebral  rheumatism  under  my  charge*  the  thermometer  marked 
110°  in  the  axilla,  yet  the  patient  got  well.  In  an  instance  of 
injury  to  the  spine  after  a  fall,  reported  by  Teale,t  the  young  lady 
lived  though  the  temperature  reached  above  122°  and  ranged  for 
days  between  112°  and  114°.  A  remarkable  case  has  also  been 
reported  of  hysteria  and  intercostal  neuralgia,  in  which  in  one 
axilla  the  temperature  registered  117°  Fahr.  aud  110°  in  the  other, 
and  the  patient  recovered.  |  The  temperature  may  also  be  tem- 
porarily very  high  from  emotion.  I  saw  this  once  in  a  frightened 
child  which  had  previously  had  but  slight  fever,  and  E.  S.  Tait 
has  reported  the  same  in  the  puerperal  state.  § 

*  See  Amer.  Jour,  of  Med.  Sci.,  Jan.  1875. 
f  Transact.  Clinical  Society  of  London,  vol.  viii. 
X  Philipson,  London  Lancet,  April,  1880. 
§  Obst.  Soc.  Transact.,  1884. 


EXAMINATION   OF    PATIENTS,  ETC.  51 

On  the  other  hand,  the  thermometer  may  show  a  depression  in 
temperature  below  the  normal.  The  body  heat  often  falls  at  the 
beginning  of  acute  peritonitis.  It  is  low  after  severe  loss  of  blood, 
or  if  exposure  to  cold  happen  in  alcoholic  intoxication,  during 
convalescence  from  acute  diseases,  and  in  melancholia.  It  is  de- 
pressed by  various  poisons,  and  has  been  observed  down  to  93.9° 
in  carbolic  acid  poisoning.*  It  is  low  in  the  insane.  It  may  be 
only  a  fraction  above  89°  in  the  axilla  in  cholera.  From  any 
other  cause  it  rarely,  however,  even  in  extreme  collapse,  sinks 
below  92°. 

Though  having  its  widest  range  of  applicability  in  fevers,  in 
other  than  febrile  states,  too,  the  thermometer  assists  materially 
in  diagnosis  and  prognosis.  It  is  invaluable,  in  many  instances, 
in  discriminating  between  functional  and  organic  aifections.  It 
aids  in  the  study  of  apoplexy,  of  palsies,  and  of  hysterical  af- 
fections, and  tells  the  true  story  in  cases  of  feigned  disease.  It 
also  enables  us  to  judge  whether  increased  frequency  of  pulse  be 
due  to  fever  or  to  debility ;  and  it  indicates  that  sweating  which 
is  not  preceded  by  a  previous  elevation  of  temperature  is  the  result 
of  exhaustion  and  not  its  cause.  There  is  probably  a  continuous 
rise  of  the  heat  of  the  body  in  all  cases  in  which  a  deposition  of 
tubercle  is  taking  place  actively  in  any  of  its  organs,  and  more 
especially  in  the  lungs ;  while,  on  the  other  hand,  I  have  noticed 
that  in  cancerous  affections  the  heat  of  the  body  is  but  little 
influenced,  and  is  sometimes  even  below  the  normal  standard. 

Such  are  some  of  the  main  facts  connected  with  the  thermom- 
etry of  disease ;  and  in  the  course  of  this  volume  there  will  often 
be  occasion  to  refer  to  others. 

*  Baumler,  in  Quaiii's  Dictionary  of  Medicine,  1883. 


CHAPTER  II. 

DISEASES   OF   THE    BKAIX   AND   SPINAL   CORD,  AND   OF 
THEIR   NERVES. 

The  study  of  the  disorders  of  the  brain,  and,  in  truth,  of  those 
of  the  entire  nervous  system,  is  very  dijfificult.  Yet  great  advance 
has  been  made  of  late  years  in  untangling  many  knotty  problems ; 
and  at  least  the  more  tangible  evidences  of  nervOus  disease  are 
clearly  recognized.  It  is  with  these  that  this  sketch  is  intended 
to  deal. 

But  before  entering  upon  a  consideration  of  the  affections  of 
the  nervous  system  it  is  proper  to  recall  a  few  salient  points  con- 
nected with  its  structure  and  functions  indispensable  to  a  recog- 
nition of  its  derangements.  We  have  constantly  to  bear  in  mind 
that  there  are  in  its  composition  nerve-cells  composing  ganglia, 
which  are  for  the  most  part  originators,  and  nerve-fibres,  which 
are  for  the  most  part  conductors,  and,  besides,  a  peripheral  termi- 
nation of  these  conductors,  which  forms  a  peripheral  nervous  sys- 
tem, chiefly  concerned  in  receiving  and  distributing  impressions. 
In  the  brain  and  spinal  cord  are  the  principal  nervous  centres 
which  originate  and  control,  and  in  the  brain  especially  our 
knowledge  of  the  subject  of  localization  and  special  function  of 
particular  points  has  become  so  extended  that  it  is  made  the  basis 
of  accurate  diagnostic  knowledge,  which  has  of  late  years  assumed 
the  greatest  practical  importance. 

Cerebral  Localization. 

Either  for  his  own  purposes  or  to  co-operate  with  the  surgeon, 
the  physician,  prior  to  intelligent  therapeutical  or  operative  proce- 
dure, must  often  satisfy  himself  of  the  seat  of  the  lesion  from  a 
great  variety  of  symptoms,  and  a  summary  of  what  we  know  of 
the  centres  in  the  brain  is  here  a  necessity. 
52 


DISEASES   OF   THE   BRAIN   AND   SPINAL  COED.  06 

The  methods  by  which,  in  animals,  the  locations  of  the  cere- 
bral centres  have  been  determined  have  been  principally  those 
of  electrical  stimulation  and  the  ablation  of  limited  areas  of  the 
cortical  gray  matter.  Fi'om  a  study  of  the  ensuing  symptoms, 
both  positive  and  negative,  spasmodic  or  paralytic,  in  the  periph- 
eral muscles  and  parts,  conclusions  are  reached  as  to  the  ana- 
tomical and  functional  relations  of  the  two.  In  this  way  the 
topography  of  the  motor  ciortical  centres  of  the  monkey  has  been 
definitely  laid  down  by  Fritsch  and  Hitzig,  Ferrier,  Horsley  and 
Schaefer,  and  others.  It  has  thus  been  ascertained  that  in  the 
monkey  the  centre  for  the  movements  of  the  head  as  a  whole  is 
placed  most  anteriorly ;  extending  from  that  part  of  the  frontal 
lobe  non-responsive  to  excitation — which  is  about  opposite  a  point 
between  the  posterior  and  middle  thirds  of  the  superior  frontal 
convolution — to  the  arm-area,  which,  on  the  convex  aspect  of  the 
hemisphere,  abuts  the  face-area  at  its  inferior  border.  The  arm- 
area  next  occupies  a  somewhat  irregularly  shaped  territory,  com- 
prising a  space  of  the  mesial  surface  directly  posterior,  bounded 
behind  by  the  trunk-centre,  and  stretching  upon  the  convex  sur- 
face below  the  leg-area  across  the  whole  space  of  the  ascending 
frontal  and  ascending  parietal  convolutions,  to  the  interparietal 
sulcus.  The  trunk-centre  upon  the  inner  aspect  occupies  but  a 
limited  space,  and  is  bounded  posteriorly  by  the  leg-centre,  w^hich 
is  situated  at  the  head  and  about  the  superior  termination  of  the 
Rolandic  fissure.  The  face-centres  occupy  the  space  about  the 
lower  termination  of  the  Rolandic  fissure,  between  the  precentral 
and  Sylvian  fissures. 

It  has  been  found  that  these  large  centres  are  compound,  that 
subdivisions  control  individual  muscles  or  movements,  and  that 
the  general  order  is  such  that  upon  the  median  aspect,  the  centres 
arranged  from  before  backward  control  successively  the  muscles 
of  the  head,  shoulder,  arm,  trunk,  leg,  and  feet.  This  is  also 
true  of  the  arrangement  upon  the  convex  or  external  surface 
of  the  hemisphere,  the  most  anterior  being  those  of  the  face. 
In  the  light  of  evolution  we  may  say  that  the  lower  the  type 
of  animal  the  more  completely  do  the  basal  ganglia  govern  the 
volitional  motor  centres,  but  that  in  proportion  to  the  elevated 
position  of  the  animal  we  see  these  volitional  centres  displaced 
toward  the  cortex,  until,  arriving  at  man,  we  find  almost  all 


54  :\IEDICAL   DIAGNOSIS. 

peripheral  movements  have  their  cerebral  reflex  centres  located 
with  more  or  less  exactness  in  certain  cortical  areas,  and  with 
more  or  less  definite  topographical  relations  to  others.  In  corre- 
spondence with  this  law  there  seems  to  be  another  governing  the 
position  of  the  centres  of  the  most  specialized  and  differentiated 
muscles,  whereby  they  are  superposed  upon  those  of  the  larger 
muscles  and  groups,  of  which  they  are  in  reality  extensions,  re- 
finements, or  specializations.*  Strong  stimulus  of  a  sub-centre 
will  implicate  a  larger  area  and  result  in  movement  of  larger 
related  muscles. 

In  man  the  centres  for  movements  of  the  trunk  and  head  as  a 
whole  are  not  so  clearly  determined  as  those  for  the  thumb  or  the 
tongue.  But  in  a  general  way  the  arrangement  of  the  cortical 
motor  centres  in  man  preserves  the  same  plan  and  order  as  in  the 
monkey.  The  facts  in  the  case  of  man  are,  of  course,  solely  the 
results  of  clinical  and  pathological  investigation,  and  it  is  need- 
less to  say  that  some  indefiniteuess  still  prevails  in  these  matters. 
The  accumulation  of  knowledge  in  this  manner  must  proceed  but 
slowly. 

The  latest  results  in  the  localization  of  human  cortical  centres 
are  indicated  in  the  annexed  sketch.  It  should  not  be  forgotten 
that  in  all  such  diagrammatic  representations  the  picture  represents 
the  fact  but  poorly.  We  know,  for  example,  that  the  t^^•o  halves 
of  the  same  brain  are  unlike.  Moreover,  there  is  never  any  hard 
and  fast  line  dividing  one  centre  from  its  neighbor.  If  they  do 
not  actually  overlap,  the  centres  certainly  pass  into  one  another  by 
indefinable  gradations.  The  strength  of  the  stimulus,  as  has  been 
intimated,  modifies  the  definiteness  of  limitation,  and  many  facts 
go  to  show  that  the  unaffected  hemisphere  has  often  a  certain 
power  of  "  substitution,"  whereby  it  can  take  up  the  function  of  its 
injured  fellow.  Certain  muscles,  indeed,  appear  to  be  represented 
bilaterally  in  each  hemisphere,  whilst,  on  the  other  hand,  there 
is,  at  least  in  the  case  of  articulate  speech,  a  location  of  the  unique 

*  A  suggestive  corroboration  of  this  law  may  be  seen  in  the  cases  reported 
bj-  Oppenheim  (Charite  Annalen,  vol.  xiii.  p.  345),  in  which  what  must  be 
considered  the  older  and  more  elementary  appreciation  of  musical  sense  and 
sound  was  preserved  in  eleven  cases  in  which  cerebral  lesions  had  destroj^ed 
more  recentl}^  acquired  articulate  and  sensory  speech-centres.  Gesture-language 
was  also  preserved. 


DISEA.SES   OF  THE   BRAIN   AND  SPINAL   CORD. 


55 


56  MEDICAL  DIAGNOSIS. 

controlling  centre  singly  upon  one  side  or  the  other  according  as 
the  pei-son  is  right-handed  or  left-handed. 

As  in  the  monkey,  so  in  man,  the  centres  for  voluntary  motion  of 
the  opposite  side  of  the  body  cluster  about  the  fissure  of  Rolando. 
Upon  the  mesial  surface  the  same  order  of  arrangement  from 
before  backward  is  preserved,  but  there  is  somewhat  less  certainty 
here  than  in  the  monkey  as  to  the  definite  areas  of  the  head  and 
trunk.  Externally,  about  the  up])cr  limit  of  the  Rolandic  fissure, 
the  leg-area  is  pretty  clearly  made  out,  extending  posteriorly  to 
a  somewhat  indeterminate  point  of  the  parietal  lobule,  and  in- 
feriorly  occupying  the  upper  third  of  the  ascending  frontt]l  and 
ascending  parietal  convolutions.  The  shoulder-  and  arm-area  in- 
cludes the  middle  third  of  these  convolutions,  whilst  in  the  lower 
third  are  located  the  centres  of  control  of  the  facial  movements. 
In  the  latter  space,  and  extending  into  the  posterior  portion  of 
the  third  left  frontal  convolution,  lies  the  centre  for  articulate 
speech,  lesion  of  which  causes  motor  aphasia.  In  connection 
with  the  subject  of  aphasia  we  may  note  that  logically  a  separate 
centre  is  required  to  correspond  to  the  clinical  fact  of  psychic 
inability  to  write, — agraphia.  Yet  the  location  of  this  centre 
is  not  clearly  established.  There  are,  then,  the  two  kinds  of 
motor  aphasia  produced  by  lesions  of  the  corresponding  centres, 
which  are  called  by  some  "aphemia,"  or  simply  motor  aphasia, 
and  "  agraphia."  But  our  complex  power  of  thought-expression 
is  made  up  of  two  other  elements  that  are  sensory ;  there  must 
be  psychical  comprehension  both  of  the  heard  and  of  the  seen 
M^ord.  The  centres  intermediating  these  functions  have  been 
made  out  with  some  approach  to  definiteness.  Lesions  of  the  first 
temporal  convolution  produce  word-deafness,  or  inability  to  com- 
prehend the  meaning  of  words  though  not  deaf  to  other  sounds. 
In  the  same  way,  word-blindness,  or  inability  to  understand  the 
import  of  written  or  printed  words,  follows  injury  of  an  adjacent 
region. 

In  reference  to  the  cortical  visual  centre  there  can  be  little 
further  doubt  that  it  is  located  in  the  occipital  lobe,  and  especially 
in  the  cuneus.  The  researches  of  Schaefer  and  Brown,*  and  the 
review  of  the  literature  by  Seguin,f  seem  to  be  conclusive  against 

*  Brain,  Jan.  1888.  f  Journ.  Nerv.  and  Ment.  Dis.,  1886,  No.  1. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD. 


57 


the  view  of  Ferrier,  that  the  visual  centre  is  in  the  angular  gyrus. 
The  production  of  hemianopsia  from  lesions  of  the  occipital  loljc, 
in  accordance  with  the  conclusions  of  Seguin,  is  shown  in  the 
accompanying  diagram  (Fig.  7).  Complete  cortical  blindness  may 
be  considered  as  a  bilateral  hemianopsia. 


Fig. 


Eight  Homoxtmous  or  Lateral  Hemianopsia,  from  Lesion  of  the  Left  Visual  Centre 
OF  THE  Cortex  or  Left  Optic  Tract.— ^,  dark  left  nasal  half-field  from  bliud  temporal  half  of 
retina;  A',  dark  right  temporal  half-field  from  blind  nasal  half  of  retina;  B,  left  eye;  £',  right 
eye ;  C,  G',  left  and  right  optic  nerves,  composed  of  the  crossed  bundles  of  fibres  ;  D,  1)' ,  left  and 
right  crossed  bundles  ;  jB,  jE',  left  and  right  occipital  lobes  ;  F,  F',  left  and  right  posterior  cornua ; 
G,  G',  "optic  radiation"  of  Gratiolet;  B,  H',  optic  chiasm  ;  I,  I',  angular  gyrus;  K,  region  of  optic 
thalamus,  geniculate  body,  and  quadrigemiiial  bodies,  collectively  termed  the  primary  optic  cen- 
tres ;  31,  M',  cuneiis  of  the  occipital  lobe,  the  cortical  visual  centre.  The  left  cuneus  and  optic 
tract  are  shaded,  to  show  lesion  of  these  parts  and  the  influence  of  the  lesion  upon  the  retiuaj. 

The  centres  for  audition,  smell,  and  taste  are  yet  undetermmed. 
The  experiments  of  Schaefer  and  Brown*  are  opposed  to  the 
previous  belief  that  located  them  as  probably  in  the  temporal 
lobe.  The  location  of  the  centres  of  tactile  or  cutaneous  sensation 
is  also  in  dispute,  but  it  appears  probable  that,  if  not  identical 
with,  they  are  at  least  contiguous  to  those  of  the  motor  functions 
of  corresponding  parts,  f 

*  Brain,  Jan.  1888.         f  See  Dana,  Journ.  Nerv.  and  Ment.  Dis.,  Oct.  1888. 


58  MEDICAL    DIAGNOSIS. 

Let  US  now  look  at  the  derangements  of  the  nervous  system. 
But  first  let  us  examine  a  few  symptoms  and  morbid  states  having 
a  general  significance  rather  than  a  specific  connection  with  any 
malady. 

DERANGED   INTELLECTION. 

The  great  instrument  of  the  intelligence,  the  brain,  manifests 
its  ailings,  whether  primary  or  merely  sympathetic,  by  derange- 
ment of  thought  of  every  conceivable  degree  and  kind, — from 
dulness  and  confusion  of  the  intellect  to  its  utter  perversion  and 
prostration.  When  one  intellectual  function  is  disturbed,  generally 
all  are,  or  soon  become  so;  yet  we  may  find  impairment  of  judg- 
ment and  of  imagination  without  deterioration  of  memory  or  of 
the  powers  of  attention.  One  of  the  most  marked  signs  of  mental 
infirmity  is  a  disordered  memory.  This  is  especially  encountered 
in  chronic  cerebral  diseases,  or  in  such  nervous  affections  of  un- 
certain seat  as  epilepsy.  Another  signal  of  mental  derangement  is 
loss  of  judgment,  or  rather  loss  of  power  to  appreciate  the  logical 
sequence  of  ideas ;  still  another  is  depression  of  mind,  or  its  op- 
posite, exaltation.  All  these  abnormal  conditions  may  happen  in 
acute  as  well  as  in  chronic  maladies,  but  they  are  more  striking  in 
the  latter,  and  become  of  more  aid  in  the  diagnosis ;  and  they  may 
or  may  not  be  joined  to  appreciable  textural  changes.  To  the 
psychologist  their  significance  is  very  great,  as  they  are  often  the 
premonitory  symptoms  of  that  departure  from  mental  health  which 
terminates  in  confirmed  insanity. 

In  acute  disturbances  of  the  brain,  whether  functional  or  or- 
ganic, we  meet  with  these  striking  phenomena  connected  with 
disordered  intellection ;  delirium,  stupor,  coma ;  and  with  these 
we  may  consider  insomnia. 

Delirium. — This  is  a  wandering  of  the  mind,  manifesting  itself 
by  the  expression  of  ill-associate<l  thoughts,  of  the  incongruity  of 
which  the  patient  is  not  conscious.  It  most  frequently  occurs  in 
those  of  susceptible  nervous  system,  and  is,  in  consequence,  more 
common  in  the  young  than  in  the  old.  It  is  almost  invariably 
united  with  restlessness,  and  increases  as  night  approaches. 

The  character  of  the  delirium  is  various.  There  is  first  the 
quiet  delirium,  of  a  low  or  passive  type.  The  patient  mutters 
incoherent  words,  moans  without  any  assignable  reason,  or  lies 
silent,  with  his  eyes  open,  his  thoughts  preoccupied  with  his  vague 


DISEASES   OF   THE   BRAIN   AND   SPINAL   CORD.  59 

illusions,  and  taking  no  notice  of  what  goes  on  around  him  in  the 
external  world.  If  strongly  aroused,  he  gives  a  rational  answer, 
but  not  a  long  or  a  connected  one,  for  he  soon  returns  to  his 
dreams  and  his  ever-changing  hallucinations.  He  picks  at  his 
bedclothes,  moves  in  bed,  and  may  even  try  to  leave  it,  although 
he  is  easily  prevented  from  so  doing. 

Then  there  is  a  delirium  of  somewhat  more  active  type,  still,  on 
the  whole,  quiet ;  the  patient  wanders,  yet  not  boisterously.  He 
is  irritable,  and  often  does  not  show  that  his  mind  is  disturbed, 
except  in  some  one  j)articular, — in  irascibility  about  trifles,  or  in 
expressions  and  modes  of  thought  foreign  to  his  nature. 

An  active,  fierce  delirium  presents  different  characteristics.  The 
patient  is  wild,  noisy  ;  he  sings,  screams,  gets  out  of  bed  ;  his  face 
during  the  excitement  becomes  congested ;  the  eye  is  bright,  often 
fiery. 

Now,  all  these  forms  of  delirium  occur  in  many  different  mala- 
dies, apd  are  far  from  being  of  necessity  linked  to  an  organic 
cerebral  affection.  Nay,  not  even  the  most  violent  kind  of  mental 
wandering  is  positively  indicative  of  a  lesion  of  the  brain  ;  at  least, 
not  of  such  a  lesion  as  can  be  determined  by  any  of  our  present 
means  of  investigation.  As  a  rule,  we  find  the  low,  quiet  de- 
lirium in  conditions  of  vital  exhaustion,  particularly  in  those 
depressed  states  of  the  nervous  system  which  are  connected  Avith 
quickened  vascular  action,  and  with  a  deterioration  of  the  blood, 
as,  for  instance,  in  the  low  fevers.  The  fierce  delirium  may, 
however,  be  associated  with  prostration  or  depraved  blood.  Thus, 
the  delirium  of  pneumonia  is  sometimes  of  a  violent  kind,  owmg 
to  the  maddening  effect  of  the  ill-oxygenated  vital  fluid  on  the 
brain.  In  most  of  the  ordinary  fevers  the  delirium  is  of  a  mod- 
erate type;  in  inflammatory  diseases  of  the  brain  and  in  acute 
mania  it  is  fierce. 

Delirium  is  not  difficult  of  recognition  ;  yet  we  must  be  careful 
not  to  confound  with  it  night  teri'ors,  those  troubled  dreams  to 
which  ailing  children  are  so  liable,  and  which  occasion  confusion 
of  thought  on  first  awaking,  and  until  consciousness  is  fully 
aroused.  Delirimn  is  most  likely  to  be  mistaken  for  insanity. 
There  is  this  palpable  difference  :  an  insane  person  is  commonly 
in  good  health  in  all  save  his  intellect ;  a  delirious  person  is  ill, 
and  exhibits  evidences  of  his  illness  besides  his  delirium.     It  is 


60  MEDICAL    DIAGNOSIS. 

true  that,  avIiou  the  patient  is  first  seen,  doubt  may  arise ;  but  it 
is  not  generally  of  long  duration.  In  the  mania  appearing  oc- 
casionally after  epileptic  fits,  or  taking  their  place,  there  may  be 
doubt  until  we  obtain  a  clear  history.  Most  perplexing  are  the 
cases  in  which  insanity  follows  or  attends  inordinate  drinking. 
But  this  is  a  subject  which  we  shall  discuss  in  reviewing  mania 
a  potu. 

Another  perplexing  group  of  cases  is  furnished  by  the  occur- 
rence of  that  singular  form  of  delirium  which  is  met  with  at 
times  in  acute  diseases,  especially  in  fevers,  and  which,  as  it  is 
apt  to  be  associated  with  insufficient  nutrition,  has  been  called  the 
delirium  of  inanition,  or  of  collapse.*  Its  outbreak  is  sudden,  like 
an  attack  of  mania,  but  it  is  found  to  be  combined  witli  a  feeble 
pulse,  with  a  skin  bathed  in  perspiration,  with  cold  hands  and  feet, 
— ^in  a  word,  with  the  signs  of  great  prostration  or  of  collapse. 
The  seizure  happens  usually  early  in  the  morning,  and  is  unex- 
pected, for  it  occurs  commonly  at  the  end  of  the  febrile  state,  and 
when  the  condition  of  the  skin  and  pulse  bespeaks  convalescence. 
The  exhausted  nervous  centre  betrays  itself  in  the  sudden  mental 
wandering,  which  has  generally  this  characteristic, — there  is  but 
one  fixed  delusion,  and  this  one  connected  with  the  subjects 
which  have  most  engrossed  the  mind  before  the  illness.  The 
seizure  lasts  from  six  to  forty-eight  hours,  and  at  its  termination 
the  patient  is  apt  to  awake  out  of  a  sleep  with  a  calm  mind,  re- 
membering, perhaps,  his  hallucination  as  a  vivid  dream.  There 
may  be  more  than  one  attack,  but  this  is  not  common ;  and  the 
duration  is  materially  abridged  by  opium  and  by  the  employ- 
ment of  stimulants  and  nourishment.  The  form  of  delirium 
under  consideration  is  not  simply  a  sequel  of  febrile  conditions. 
It  may  also  succeed  exhausting  discharges  and  drains  from  the 
system,  or  inability  to  obtain  or  to  digest  the  proper  amount  of 
food.  Thus,  it  may  happen  in  malignant  diseases  of  the  stomach ; 
also  in  mere  gastric  irritability  and  persistent  vomiting.  The 
most  marked  instance  of  this  kind  of  mental  wandering  I  have 
encountered  was  associated  with  functional  gastric  disorder,  which 


*  See  Weber,  Medico-Chirurg.  Transact.,  1865;  Becquet,  Arch.  Gen.  de 
Medecine,  1866 ;  also  the  Clinical  Lectures  of  Chomel  and  of  Trousseau  ; 
Nothnagcl,  "  Antemia  of  the  Brain,"  in  Ziemssen's  Cyclopaedia. 


DISEASES    OF    TPIE    BRAIN    AND    SPINAL    CORD.  61 

prevented  enough  food  from  being  retained.  In  this  patient  the 
hallucination  was  on  one  subject, — a  business  matter  which  had 
been  annoying  him  greatly  just  before  his  illness  became  decided. 

Delirium  is  at  times  simulated.  This  differs  from  real  delirium 
by  the  absence  of  all  other  signs  of  illness,  and  by  the  sameness 
of  the  mental  wandering.  In  a  case  of  feigned  delirium  I  met 
with,  the  man  whined  when  spoken  to,  and  pretended  to  rave ; 
but  his  ideas  always  ran  on  the  same  subject,  and  he  was  very 
solicitous  about  his  food,  and  about  other  matters  of  which  a 
delirious  person  takes  no  notice.  Delirium  is  more  or  less  con- 
tinuous ;  once  delirious,  a  patient  remains  so  for  some  time,  and 
until  the  exciting  cause  subsides.  In  this  respect  hysterical  de- 
lirium is  exceptional ;  it  does  not  last  long,  or  it  intermits  and 
then  reappears. 

Stupor. — A  blunted  state  of  mind,  a  partial,  drowsy  uncon- 
sciousness, constitutes  the  phenomenon  called  stupor.  The  patient 
lies  in  a  deep  slumber,  from  which  he  cannot  be  roused  save 
with  great  difficulty,  and  when  roused  he  answers  reluctantly 
and  briefly,  and  soon  resumes  his  heavy  sleep.  The  expression 
of  his  face  is  dull,  yet  now  and  then  a  ray  of  intelligence,  excited 
by  some  object  which  attracts  his  attention  or  by  some  pleasant 
reverie,  flits  across  his  features. 

Stupor  is  met  with  in  several  cerebral  affections,  and  seems  to 
be  chiefly  owing  to  a  congestion  of  the  brain.  It  is  frequently 
seen  in  typhoid  fever,  immediately  after  an  epileptic  fit,  or  as  the 
result  of  narcotic  poisons,  and  is,  in  these  states,  also  probably 
due  to  cerebral  congestion.  But  there  is  nothing  pathognomonic 
about  it  in  these  various  conditions,  nothing  by  which  we  can 
judge  positively  of  its  origin. 

Coma. — Coma  is  complete  loss  of  consciousness :  perception 
and  volition  are  alike  suspended,  and  there  is  an  appearance 
of  the  profoundest  sleep.  The  face  wears  a  confused  look;  the 
pupils  are  sluggish,  often  dilated ;  the  mouth  is  open,  the  tongue 
dry.  Sensation  may  be  blunted,  but  is  not  destroyed ;  nor  is 
motion,  for  the  patient  moves  when  his  skin  is  pinched  or  tickled. 

Coma  always  betokens  a  serious  disturbance  of  the  functions 
of  the  brain.  It  is  often  witnessed  in  cerebral  lesions,  as  from 
pressure  from  blood  or  fluid  in  brain -substance  or  in  ventricles, 
more  rarely  from  tumors,  abscesses,  or  thrombosis.     The  most 


G2  MEDICAL    DIAGNOSIS. 

thoroiigli  coma  is  seeu  in  apoplexy ;  it  comes  on  quickly,  and 
is  attended  with  a  noisy  respiration  and  a  slow  pulse.  Anothei' 
form  of  coma,  scarcely  less  complete,  is  caused  by  narcotic  poison- 
ing ;  it,  however,  does  not  appear  suddenly,  and  when  from  opium 
is  associated  with  contraction  of  the  pupils.  The  coma  of  fevers 
and  of  acute  diseases,  whether  cerebral  or  not,  is  also  gradually 
produced,  but,  unlike  that  due  to  the  toxical  effect  of  opium,  is 
ordinarily  preceded  for  days  by  insomnia,  by  delirium,  and  by 
other  signs  of  cerebral  disturbance.  The  coma  of  epilepsy  is 
recognized  by  its  following  epileptic  seizures.  In  Bright's  dis- 
ease, among  the  nervous  phenomena  of  which  coma  as  well  as 
stupor  and  delirium  may  happen,  the  loss  of  consciousness  is 
apt  to  occur  subsequently  to  either  of  the  two  other  morl:)id  phe- 
nomena, and  its  cause  is  made  manifest  by  finding  albumen  and 
tube-casts  in  the  urine,  and  by  the  general  evidences  of  uraemia, 
Urremic  coma  may,  however,  come  on  suddenly  and  pass  off 
suddenly.  It  is,  as  a  rule,  associated  with  low  temperature  and 
dilated  pupils. 

Sometimes  a  person  appears  to  be  comatose  when  his  intellect 
is  but  little  disordered.  He  may  be  paralyzed,  and  not  have  the 
power  to  communicate  his  ideas,  from  crippled  articulation  or  in 
connection  with  aphasia.  This  state  is  distinguished  from  coma 
by  noting  that  the  patient's  attention  is  always  directed  to  the 
questions  asked  him,  nay,  that  he  strives  to  answer  them,  but 
cannot ;  and  that  generally  he  has  lost  control  over  the  muscular 
movements  of  one  side  or  of  both  sides  of  the  body. 

Insomnia. — The  deprivation  of  sleep  is  a  concomitant  of  cere- 
bral congestion  and  of  the  earlier  stages  of  cerebral  inflammation. 
But  a  person  may  be  sleepless  from  excessive  pain,  from  exhaus- 
tion, from  grief,  from  mental  excitement  or  fatigue,  or  from  the 
too  free  use  of  coffee  or  of  tea ;  sometimes  insomnia  is  engendered 
by  habitually  working  late  at  night.  However,  in  several  of 
these  states  congestion,  of  active  or  passive  character,  is,  in  all 
likelihood,  the  immediate  cause  of  the  wakefulness. 

.  Insomnia  often  precedes  or  attends  delirium,  as  appears  in 
typhoid  fever.  Among  purely  nervous  affections  it  is  most  marked 
in  delirium  tremens.  It  is  a  very  troublesome  symptom;  but, 
occurrino-  in  so  many  abnormal  conditions,  it  cannot  be  looked 
upon  as  having  a  distinct  and  specific  diagnostic  value. 


DISEASES   OF   THE   BRAIN   AND   SPINAL   CORD.  63 


DERANGED    SENSATION. 

The  signs  of  perverted  or  impaired  sensation  are  numerous. 
Tliey  may  either  be  due  to  an  alteration  of  the  general  sensibility 
or  be  the  signals  of  a  derangement  of  a  nerve  of  special  sense. 
Let  us  look  at  a  few. 

Hypersesthesia. — An  exalted  sensibility  of  surface  nerves, — 
of  those  of  the  skin,  the  mucous  membranes,  or  even  of  those  of 
deeper-seated  structures, — in  other  words,  a  hypersesthesia  of  these 
parts,  is  a  symptom  of  importance ;  not  so  much,  perhaps,  on 
account  of  the  light  thrown  by  it  on  any  particular  disease,  as 
because  its  presence  makes  it  requisite  to  determine  its  origin  and 
to  separate  its  phenomena  from  those  of  inflammation.  We  may, 
as  a  rule,  distinguish  the  peripheral  sensitiveness  from  the  tender- 
ness of  subjacent  inflammation,  by  its  extension  over  a  larger 
surface ;  by  deep  pressure  producing  no  more  pain  than  a  light 
touch  ;  by  the  absence  of  signs  of  functional  disturbance  of  the 
part  involved  apparently  in  inflammatory  disease ;  by  the  uni- 
formity of  the  painful  sensation,  no  matter  how  long  the  duration 
of  the  disorder,  though  the  sensitiveness  exhibits  distinct  inter- 
missions and  exacerbations. 

Hypersesthesia  is  not  linked  to  organic  diseases  of  the  brain  or 
spinal  cord.  Indeed,  it  is  in  them  not  common,  and  rarely  reaches 
a  high  degree  of  development.  By  far  the  most  usual  causes  of 
hypersesthesia  are  impoverished  blood  and  that  mysterious  malady 
called  hysteria ;  therefore  conditions  which  bespeak  lowered  vital 
and  nervous  power.  Sometimes  hypersesthesia  is  produced  by 
rheumatism  or  by  gout,  by  lithsemia,  or  by  disturbance  of  the 
function  of  the  kidney.  It  is  further  met  with  in  epidemic  in- 
fluenza; in  hydrophobia;  in  inflammations  in  internal  cavities 
involving  the  ganglia  of  the  great  sympathetic ;  after  the  use  of 
ergot  and  of  opium ;  and  in  some  diseases  of  the  skin.  It  also 
attends  paroxysms  of  neuralgia,  as  witnessed  in  thp  exquisite 
.sensitiveness  of  the  skin  during  an  attack  of  tic  douloureux  ;  the 
painful  spots,  too,  in  the  course  of  local  neuralgias  are  thought  to 
be  chiefly  hypersesthetical. 

The  seat  of  the  heightened  sensibility  is  ordinarily  in  the  skin, 
in  the  distribution  of  the  cutaneous  nerves.  Yet  hypersesthesia 
may  affect  the  nerves  of  the  special  senses,  manifesting  itself,  for 


G4  MEDICAL   DIAGNOSIS. 

instance,  by  intolerance  of  light  or  of  sound.  But  this  variety  of 
hyperesthesia  need  here  be  but  alluded  to,  as  we  shall  presently 
look  niore  fully  at  the  signs  of  disturbance  of  these  nerves.  Of 
the  minute  anatomical  changes  in  hypertesthcsia  we  know  nothing. 
The  physiological  basis  for  the  increased  sensation  may  be  cither 
in  the  peripheral  nerves,  or  in  the  irritability  of  a  cerebral  centre 
or  of  the  conducting  fibres  of  the  spinal  cord,  especially  of  those 
of  the  posterior  columns.  The  exaltation,  or,  perhaps,  more 
strictly  speaking,  the  perversion,  of  sensation  may  disclose  itself 
in  other  signs  besides  pain  and  tenderness ;  in  a  general  irrita- 
bility of  the  surface,  in  itching,  in  formication,  and  in  unnatural 
feelings  of  various  kinds,  such  as  the  feeling  of  tingling,  of  "  pins 
and  needles,"  of  goose-flesh,  of  flushing,  of  the  trickling  of  cold 
water,  of  shock-like  sensations.  This  perverted  sensation,  whether 
purely  subjective  or  to  the  touch,  is  termed  "  paresthesia." 

Let  us  now  look  at  hyperresthesia  in  connection  with  affections 
of  the  nervous  system,  especially  with  those  of  the  brain  and  spinal 
cord. 

Hyper eesthesia  is  general  and  combined  loith  signs  of  organic 
disease. — We  find  this  in  tumors  pressing  upon  the  pons  Varolii 
and  corpora  quadrigemina,  or  in  alterations  or  injuries  of  the  pos- 
terior columns  of  the  cord,  or  in  injuries  dividing  transversely 
and  completely  a  lateral  half  of  the  spinal  cord,  in  some  cases  of 
cerebral  meningitis,  and  in  spinal  meningitis  in  which  the  pos- 
terior nerve-roots  are  implicated.  We  have  in  all  these  conditions 
a  hyperesthesia  more  or  less  extensive,  and  combined  with  other 
striking  evidence  of  nervous  disease,  often  with  pain.  But,  in 
making  up  our  minds  as  to  the  cause  of  the  extended  hyper- 
esthesia, the  sensitiveness  in  general  neuralgias  and  in  reflected 
irritation  to  the  posterior  columns,  especially  in  hysterical  sub- 
jects, must  always  be  remembered. 

Hypersesthesia  is  limited  to  one  side. — An  injury  or  degeneration 
of  only  one  posterior  column  \x\\\  give  us  increased  sensibility  on 
the  same  side  as  the  lesion.  Limited  hyperesthesia  belongs  much 
more  closely  to  spinal  than  to  cerebral  disease.  We  also  find  it  in 
connection  with  special  neuralgias,  and  the  sensitive  skin  shows 
augmented  electrical  sensibility.  •  In  some  instances  of  limited 
as  well  as  of  more  extended  hyperesthesia  nothing  abnormal  can 
be  detected,  and  the  disorder  must  be,  with  our  present  knowledge, 


DISEASES    OF    THE    BRAIN    AND   SPINAL   CORD.  65 

set  down  as  a  neurosis,  one  concerning  which  it  remains  uncertain 
whether  it  is  of  central  or  of  peripheral  origin. 

AnaBSthesia. — Loss  of  sensation,  or  anaesthesia,  is  of  various 
degrees.  It  may  be  complete  or  partial, — a  perfect  absence  of 
sensibility,  or  its  mere  benumbing.  Not  to  speak  of  its  meaning 
when  displaying  itself  only  in  the  organs  of  the  special  senses, 
we  find  it  in  diseases  of  the  brain  ;  in  several  of  the  neuroses ; 
after  large  doses  of  Indian  hemp,  of  lead,  of  arsenic ;  we  see 
it  ushering  in  attacks  of  neuralgia  ;  accompanying  or  preceding 
cutaneous  eruptions,  such  as  elephantiasis  or  pemphigus ;  in  hys- 
teria, in  syphilis,  in  rheumatism  ;  and  as  the  result  of  diphtheria, 
of  pressure  on  nerve  trunks,  of  peripheral  nerve  irritation,  and  of 
disturbances  of  circulation  and  abnormal  conditions  of  the  blood. 
In  the  mucous  membranes,  too,  it  may  exist,  in  consequence  either 
of  the  general  causes  just  mentioned,  or  of  some  purely  local 
irritation  ;  and  it  may  affect  the  muscles.  But  it  does  not  attack 
these  structures  nearly  as  often  as  it  does  the  skin  :  indeed,  when 
we  speak  of  ansesthesia  without  qualifying  it,  we  mean  that  of 
the  cutaneous  nerves.  In  the  parts  affected  with  anaesthesia  the 
nutrition  is  less  active,  and  there  is  a  feeling  of  numbness.  The 
temperature  is  diminished,  and,  if  the  impaired  sensibility  be  at 
all  general,  the  patient  is  not  susceptible  to  alternations  of  heat  or 
cold.  Frequently  the  circulation  in  the  skin  is  retarded,  occasion- 
ing a  perceptible  lividity  and  discoloration  of  the  surface  ;  or 
there  are  coexisting  trophic  changes,  such  as  glazing  of  the  skin, 
and  grayness  of  hair.  The  electrical  sensibility  is  diminished,  as 
is  made  very  manifest  by  the  use  of  the  wire  brush  with  either 
the  faradaic  or  the  galvanic  current.  In  hysterical  ansesthesia 
this  is  a  particularly  striking  feature. 

Loss  of  sensation  has  a  much  more  constant  connection  with 
organic  affections  of  the  nervous  centres  than  increased  sensi- 
bility, which,  however,  may  precede  it.  In  the  insane,  especially 
in  monomaniacs,  anaesthesia  is  common,  and  ordinarily  very  ex- 
tended :  so,  too,  in  general  paralysis.  Indeed,  with  few  excep- 
tions, an  extended  anaesthesia  points  to  an  affection  of  the  nervous 
centres.  It  may  in  these  organic  cases  be  both  general  and  very 
complete.*    Loccdized  anaesthesia  may  usher  in  acute  attacks  of  cere- 

*  As  in  a  case  reported  by  "Winter,  quoted  Sclimidt's  Jahrt..  1883.  No.  1. 

5 


C)(i  MEDICAL    DIAGNOSIS. 

bral  disease,  and  sonietinies  exists  for  years  before  any  marked 
cerebral  symptoms  are  ]>ereeived.  Thus,  a  ease  of  apoi)lexy  ^^•as 
observed  by  Anch'al  *  in  which  deficient  sensation  was  noticed  at 
various  portions  of  the  thorax  for  a  long  time  previous  to  the  loss 
of  consciousness  ;  another  in  which  the  tips  of  the  lingers  were 
benumbed,  and  felt  continually  as  if  they  had  been  subjected  to 
intense  cold.  Forbes  AVinslowf  mentions  instances  in  which  cir- 
cumscribed conditions  of  impaired  sensation  were  the  premonitory 
symptoms  of  softening  of  the  brain  ;  the  defective  feeling  being 
manifested  in  some  cases  in  the  skin,  in  others  in  the  tongue  and 
fauces. 

If  the  defective  sensibility  be  owing  to  a  spinal  malady,  it  is 
generally  found  in  the  lower  extremities,  and  coexists  with  paral- 
ysis. Amcsthesia  of  spinal  origin  is  usually  indicative  of  the 
gray  matter  of  the  cord  having  been  disturbed  or  altered  ;  and,  in 
accordance  with  the  well-known  physiological  law  of  the  decus- 
sation of  sensitive  impressions  in  the  cord,  disease,  if  only  of  one 
posterior  half,  is  followed  by  lost  sensation  on  the  opposite  side  of 
the  body.  One-sided  anaesthesia,  affecting  even  the  face  up  to  the 
middle  line,  is  sometimes  met  with  in  hysterical  subjects  as  the  re- 
sult of  ovarian  irritation,  or  after  typhoid  fever,|  and,  though  pre- 
sumably cerebral,  the  pathology  is  unsettled.  But  strictly-limited 
one-sided  anaesthesia  is  more  apt  to  be  found  in  a  distinct  brain 
lesion,  and  the  particular  affection  occasioning  the  "  hemiauffis- 
thesia"  is  disease  of  the  white  substance  just  outside  of  the  optic 
thalamus,  of  the  posterior  part  of  the  internal  capsule,  on  the  side 
of  the  brain  opposite  to  the  side  of  the  body  which  shows  the 
anaesthesia.  Wilks,  however,  has  questioned  this  view,  and  states 
that  complete  hemiansesthesia  is  always  associated  witli  functional 
palsy.§  Whatever  the  association,  the  insensibility  is  generally 
complete  as  to  touch,  pain,  temperature,  and  electricity.  Taste, 
smell,  and  hearing  are  also  abolished  on  the  one  side,  and  the  eye 
on  the  anaesthetic  side  loses  its  acuteness  of  vision  and  of  percep- 
tion of  color.     Color-blindness  is  complete  or  partial ;  ||  the  degree 

*  Clinique  Medicale,  tome  v. 

f  Obscure  Diseases  of  the  Brain,  p.  549. 

J  Calraet,  Bulletin  de  la  Societe  Medicale  des  Hupitaux,  1876. 

§  Guy's  Hospital  Keports,  1883. 

II  Fere,  Archives  de  Neurologie,  Nos.  8  and  9,  1882. 


DISEASES    OF    THE    BRAIN    AlSTD   SPINAL    CORD.  67 

of  deafness  corresponds  'witli  that  of  tlic  cutaneous  insensiljility.* 
Hemiansesthesia  is  a  not  uncommon  symptom  between  tlie  attacks 
of  hystero-epilepsy. 

A  localized  form  of  angesthesia  happens  now  and  then  in  conse- 
quence of  an  affection  of  the  fifth  nerve.  The  extent  of  loss  of 
sensation  depends  much  upon  the  part  of  the  nerve  at  which  the 
cause  of  disturbance  is  seated.  The  skin  of  the  nose  and  check 
may  become  devoid  of  sensation  ;  the  reflex  movements  of  the  mus- 
cles of  the  face  may  cease ;  the  conjunctiva,  or  the  whole  surface  of 
the  eye,  or  one-half  of  the  tongue,  may  be  deprived  of  sensibility. 
Only  one  of  these  phenomena,  or  all  conjointly,  may  be  encoun- 
tered, according  as  part  of  one,  or  one,  or  all  of  the  branches 
of  the  fifth  nerve  are  affected.  Sometimes,  as  Romberg  proves, 
trigeminal  ansesthesia  is  of  rheumatic  origin.  When  it  is  com- 
plicated with  disturbed  functions  of  adjoining  cerebral  nerves,  it 
may  be  assumed  that  the  cause  is  seated  at  the  base  of  the  brain. 

Ansesthesia  is  sometimes  the  result  of  reflex  action.  It  may 
thus  arise  in  disorders  of  any  of  the  viscera,  and  from  an  irrita- 
tion of  any  sensitive  nerve.  It  has,  for  instance,  been  observed 
in  both  lower  limbs  in  sciatica. f 

Very  often  numbness  and  other  altered  sensations  are  com- 
plained of,  and  yet  the  whole  is  subjective ;  when  tested,  anses- 
thesia is  not  found.  In  endeavoring,  indeed,  to  form  an  opinion 
of  the  existence  or  the  completeness  of  ansesthesia,  we  do  not 
trust  to  the  patient's  statements.  We  touch  the  part  lightly 
with  the  finger  or  a  feather  while  his  eyes  are  shut,  and  the  skin 
is  pinched  or  a  pin  used  to  ascertain  the  extent  of  the  impaired 
sensation.  Or  we  resort  to  means  by  which  we  can  make  accurate 
comparisons ;  and  one  of  the  best  is  to  pursue  the  method  employed 
by  Weber,  which  consists  in  determining  how  closely  the  points 
of  a  pair  of  compasses  sheathed  with  cork  may  be  approximated 
on  the  skin  and  yet  be  felt  as  two  distinct  points.  An  instrument 
for  the  same  purpose,  called  the  "  sesthesiometer,"  was  invented  by 
Sieveking  (Fig.  8),  and  is  very  much  the  same  as  the  lighter  one 
of  Brown-Sequard  now  in  common  use.  An  instrument  com- 
bining the  principle  of  the  beam  compass  with  that  of  the  mathe- 


*  Walton,  Brain,  January,  1883. 

f  Brown-Sequard,  Central  Nervous  System,  Tenth.  Lecture. 


68 


.A[EDICAL    DIAGNOSIS. 


matioal  one  lias  been  contrived  by  Oule,*  and  one  with  ivory 
points,  -by  Manonvriez.f  The  points  of  the  a3sthesi6meter, 
wlietlier  bhmtcd  or  sharp,  shonld  bo  put  down  lightly  and 
sinuiltancously,  and  parallel  with  the  direction  of  the  cntaneous 


Fto.  8. 


Tlie  aisthesiometer. 


nerves ;  at  all  events,  the  same  relative  direction  should  be  pre- 
served in  making  comparative  estimates. 

To  understand  any  results  obtained  regarding  the  tactile  sense, 
it  is  necessary  that  we  should  be  aware  how  this  diifers  in  some 
parts  of  the  body.  JNIost  Avorks  on  physiology  contain  an  account 
of  the  researches  of  Weber  and  of  those  who  have  prosecuted  the 
inquiry  he  started ;  yet  a  few  of  the  conclusions  may  be  here  ad- 
vantageously mentioned.  At  the  tip  of  the  tongue  two  points 
can  be  readily  distinguished  when  separate  from  each  other  only 
about  2^2"  of  an  inch,  or  half  a  Paris  line ;  at  the  palmar  surface 
of  the  third  phalanx  the  limit  is  one  line  ;  on  the  palmar  surface 
of  the  second  phalanx,  two  lines,  the  same  on  the  red  surface  of 
the  lips ;  on  the  palm  of  the  hand,  the  cheek,  and  the  extremity 
of  the  great  toe,  five  lines ;  on  the  back  of  the  hand,  at  the 
knuckles,  eight  lines  ;  at  the  lower  part  of  the  forehead,  ten  lines  ; 
on  the  skin  over  the  patella  and  dorsum  of  the  foot,  eighteen 
lines ;  over  the  middle  of  the  arm,  thigh,  and  over  the  spine, 
thirty  lines.  But  these  observations  are  found  to  vary  somewhat 
even  in  healthy  persons,  some  being  able  to  distinguish  at  a  shorter 
distance  than  others. 


*  Beale's  Archives  of  Medicine,  vol.  i. 
t  Archives  de  Physiologie,  187G. 


DISEASES    OF    THE    BRAIN   AND^  SPINAL    COliD.  GO 

Besides  the  impairment  or  loss  of  tactile  discrimination,  the 
altered  sensibility  may  sliow  itself  in  the  loss  of  the  faculty  of 
feeling,  pinching,  pricking,  and  other  acts  which  excite  pain  (anal- 
gesia) ;  or  in  insensibility  to  tickling ;  or  in  the  want  of  apprecia- 
tion of  heat  or  cold ;  or  in  the  loss  of  the  sensation  which  attends 
muscular  contraction,  whether  produced  by  the  will  or  by  an  elec- 
trical current.  Now,  it  is  of  interest  in  individual  cases  to  note 
which  particular  kind  of  sensibility  is  affected,  though,  as  yet,  we 
are  not  in  possession  of  sufficient  facts  to  draw,  from  the  absence 
of  one  form  of  sensibility  or  the  other,  any  positive  conclusions  as 
to  the  seat  or  character  of  the  disease. 

In  affections  of  the  base  of  the  brain  the  patient  feels  three 
points  instead  of  the  two  of  the  sesthesiometer.*  In  sclerosis  of 
the  cord  the  sensation  is  retarded  rather  than  lost.f  A  form  of 
perverted  sensibility,,  which  may  or  may  not  be  associated  with 
anaesthesia,  consists  in  the  sensibility  being  more  or  less  perfect, 
while  there  is  doubt  as  to  the  side  touched ;  indeed,  the  touch  is 
commonly  felt  at  a  corresponding  part  of  the  other  limb.  This 
aUochiriaX  is  most  generally  found  in  association  with  organic 
spinal  disease ;  but  it  may  also  manifest  itself  in  hysteria.  A 
sufficient  physiological  explanation  of  the  erroneous  reference  of 
impressions  is  still  wanting.  In  a  case  recorded  by  Ferrier§  the 
reversal  showed  itself  also  in  the  reflex  reactions.  Tickling  the 
sole  of  one  foot  caused  retraction  of  the  other ;  tickling  the  inside 
of  one  thigh  produced  flexion  of  the  other. 

Muscular  ansestliesia  has  been  alluded  to.  It  is  closely  con- 
nected with  the  power  we  possess  of  estimating  weight,  the  "  mus- 
cular sense ;"  and  the  loss  of  ability  of  perceiving  differences  in 
small  weights,  or  the  impairment  of  the  sense  of  muscular  move- 
ment and  effort,  is  its  most  common  form.  Another  form  is  the 
loss  of  the  power  of  appreciating  muscular  contraction,  and  the 
deficiency  of  sensation  is  then  most  readily  tested  by  examination 
by  the  faradaic  current ;  the  contraction  of  the  muscles  produces 
no  feeling.  Muscular  anaesthesia  is  frequently  combined  with 
inability  to  determine  the  extent  of  any  movement,  or  the  position 

*  Brown-Sequard,  Archives  de  Physiologie,  t.  i.  No.  3. 

t  Vulpian,  ibid. 

X  Obersteiiier,  Brain,  July,  1881. 

I  Brain,  October,  1882. 


70  MEDICAL    DIAGNOSIS. 

of  the  limbs,  when  the  eyes  arc  closed  ;  it  may  or  may  not  be 
associated  with  eutaneous  aiuesthesia.  It  is  not  uncommon  in 
hysteria  and  in  locomotor  ataxia.  Here  the  loss  of  the  appreci- 
ation of  the  positi(Mi  of  the  limbs  and  that  of  the  sense  of  mus- 
cular eifort  are  the  more  usual  of  its  varieties.  AMicn  the  muscles 
are  completely  paralyzed,  the  muscular  sense  cannot  be  tested. 

Antesthesia  and  hypersesthesia  follow,  or,  to  speak  more  accu- 
rately, manifest  themselves  only  in  connection  with,  external  im- 
pressions. Let  us  now  look  at  some  abnormal  sensations  which 
arc  not  objective,  but  subjective, — arising  independently  of  exter- 
nal impressions.     Headache  and  vertigo  are  of  this  character. 

Headache. — In  every  case  of  headaclie  we  must  first  ascertain 
that  the  pain  really  originates  within  the  cranium,  and  tliat  it  is 
not  owing  to  supra-orbital  neuralgia  ;  to  rheumatism  of  the  scalp; 
to  disease  of  the  bones  ;  to  periostitis,  syphilitic;  or  otherwise ; 
or  to  aifections  of  the  ear.  To  accomplish  this  is  generally  not 
difficult.  An  inquiry  into  the  history  of  the  case,  the  locality 
of  the  pain,  and  its  augmentation  on  pressure  in  most  of  the 
disorders  named,  furnish  evidence  which  decides  the  source  of 
the  cephalalgia  to  be  external  to  the  cranium. 

Another  joossible  c^use  of  headaclie,  always  to  be  kept  in  mind, 
has  been  made  clear  by  the  labors  of  eye-surgeons.  It  occurs  in 
persons  who  have  headache  more  or  less  intense,  with  abnormal 
sensations  in  the  skin  of  the  scalp,  and  at  times  vertigo  and  spasm 
of  the  eyelids  and  occipito-frontal  muscle.  The  near  use  of  their 
eves  increases  tlieir  distress.  When  the  eye  is  carefully  examined, 
an  optical  defect  is  found,  especially  hyperopia  or  astigmatism. 
Again,  we  may  have  defective  vision,  with  sleeplessness  and  severe 
headache,  dependent  on  decayed  teeth,  and  disappearing  with  their 
removal.* 

Having  settled  that  none  of  these  conditions  are  present,  we 
have  to  determine  the  probable  cause  of  the  headache, — a  question 
the  solution  of  which  depends  frequently  more  Upon  the  symptoms 
attending  the  pain  than  upon  its  character.  But  let  us  glance  at 
some  of  the  common  causes  and  cliaracteristics  of  intra-cranial 
headache. 

Headache  is  a  rarely  absent  symptom  of  disease  of  the  brain. 

*  Case  reported  by  Ogle,  Medical  Times  and  Gazette,  Aug.  1872. 


DISEASES    OP    THE    BRAIN    AND   SPINAL    CORD.  71 

111  acute  inflammation  it  is  generally  agonizing,  and,  while  subject 
to  exacerbations,  continuous ;  it  is  associated  with  fever,  with  vom- 
iting, although  tlie  tongue  remains  clear,  and  with  delirium.  In 
abscesses  of  the  brain,  in  softening,  and  in  similar  affections  which 
run  a  chronic  course,  the  headache  is  less  violent,  and  only  occasion- 
ally paroxysmal ;  it  is  usually  accompanied  by  signs  of  disturbed 
intellection  and  of  deranged  motion.  In  tumor  of  the  brain  the 
headache  is  apt  to  be  severe  and  paroxysmal,  but  intellection  is  not 
at  first  much  affected.  In  congestion  of  the  brain  the  pain  is 
dull,  increased  by  stooping  or  lying  down,  by  long  sleep,  and  by 
bodily  or  mental  fatigue  ;  its  concomitants  are  a  flushed  face,  throb- 
bing of  the  arteries  of  the  neck,  an  eye-ground,  as  seen  with  the 
ophthalmoscope,  in  which  the  vessels,  especially  the  veins,  are 
turgid,  and  a  heated  head,  with  increased,  temperature,  as  shown 
by  the  surface  thermometer.  A  form  of  congestive  headache,  apt 
to  be  relieved  by  bleeding  at  the  nose,  is  often  seen  in  young 
people  at  the  age  of  puberty  :  the  attacks  are  brought  ou  by 
running  or  other  violent  exercise.  In  diseases  of  the  meninges, 
especially  those  of  a  chronic  character,  the  pain  is  constant  and 
fixed,  and  sometimes  very  sharp.  The  latter  kind  of  pain  when 
persistent  is  significant  either  of  disease  of  the  membranes,  or,  at 
least,  of  parts  of  the  superficial  structure  in  contact  with  them,  and 
is  usually  felt  at  the  place  on  the  head  which  corresponds  to  the 
seat  of  the  lesion  within  the  skull.  Generally  there  is  in  menin- 
geal affections  coexisting  heat  of  forehead,  with  signs  of  local 
vascular  excitement. 

Nervous  or  neuralgic  headache  is  most  common  in  women,  es- 
pecially in  anemic  women.  It  is  unremitting  and  very  severe,  yet 
of  short  duration  ;  but  after  it  is  over  there  is  great  lassitude,  and 
even  some  local  soreness.  It  is  not  attended  with  rise  of  tem- 
perature, or 'with  any  signs  of  disturbance  of  the  brain,  except 
at  times  with  a  confusion  of  vision  and  an  inability  to  carry  on  a 
connected  train  of  thought.  Anything  that  agitates  the  nervous 
.  system  produces  an  attack ;  stimulants  and  food  often  relieve 
it.  To  the  class  of  headache  under  consideration  may  be  referred 
many  cases  of  megrim  or  migraine. 

But  migraine,  sick  headache,  or  hemicrania,  has  ordinarily 
certain  symptoms  which  set  it  apart.  The  pain  is  usually  at- 
tended by  nausea  and  vomiting,  is  generally  at  first  one-sided, 


72  MEDICAL   DIAGNOSIS. 

aiul  is  accompanied,  or  more  often  preceded,  bv  visual  disorder, 
such  as  a  bright  spot  gradually  enlarging.  The  disturbance  of 
vision  begins  suddenly,  lasting  perhaps  for  half  an  hour  before 
the  headache  begins,  and  is  at  times  associated  with  tingling  on 
one  side,  with  difficulty  in  speech  and  confusion  of  ideas.  The 
headache  often  begins  in  the  temple,  and  is  very  severe;  it  spreads 
over  the  head,  it  may  extend  to  the  neck,  or  may  leave  the  side 
originally  ati'eeted  to  become  agonizing  on  the  other.  There  may 
be  soreness  of  the  head  with  the  pain,  and  there  is  often  ])allor 
of  the  face,  and  a  contraction  of  one  pupil.  Coldness  of  the 
extremities  is  not  uncommon,  and  the  patient  vomits  bile.  This 
bilious  vomiting  often  terminates  the  attack,  which  comes  on  only 
in  paroxysms. 

Si/mpafhcfic  headache  is  found  mainly  in  connection  with  dis- 
orders of  the  alimentary  tube  and  of  the  nterus,  and  is  often 
worse  in  the  morning,  before  food  has  been  taken. 

Headache  may  be  dependent  upon  various  poisons,  whcthei" 
generated  in  the  system  or  introduced  from  without ;  for  instance, 
in  diseases  of  the  kidney,  particularly  Bright's  disease,  the  reten- 
tion of  a  large  quantity  of  urea  in  the  blood  becomes  the  source 
of  persistent  pain  in  the  head.  In  lead  poisoning,  in  opium-eaters, 
in  drunkards,  after  the  use  of  strychnine  or  of  large  quantities  of 
quinine,  headache  is  common ;  and  it  is  very  likely  that  in  persons 
with  faulty  assimilation  certain  ptomaines  give  rise  to  the  headache. 

In  studying  headache  as  a  symptom,  we  must  always  note  what 
influence  position  and  movements  of  the  head  have  on  the  i)ain  : 
whether,  for  instance,  stooping,  swinging  the  head  from  side  to 
side,  or  rising  rapidly  from  the  horizontal  to  the  erect  posture 
affect  it,  and  cause  it  to  be  combined  with  vertiginous  or  other 
abnormal  sensations.  In  headache  connected  with  organic  disease 
of  the  brain  the  pain  is  increased  by  whatever  increases  the  blood- 
pressure, — by  stooping,  by  coughing,  by  any  effort.  The  site  of 
pain  bears  no  very  definite  relation  to  the  site  of  lesion,  except  the 
lesion  be  near  the  surface.  AVith  severe  paroxysms  of  pain  vomit- 
ing often  occurs.  Headache  increased  by  the  erect  posture  and 
relieved  bv  Iving  down  bespeaks  an  antemic  condition  of  the  brain. 

Vertigo. — This  is  a  transitory  feeling  of  swimming  of  the 
head,  a  sense  of  falling,  or  illusory  movements  of  external  objects. 
The  sensation  is  apt  to  occur  whenever  the  circulation  within  the 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  73 

cranium  is  disturbed,  and  is  often  symptomatic  of  a  disease  of  the 
heart,  liver,  kidneys,  especially  Bright's  disease,  or  of  an  affection 
of  the  stomach,  or  of  gout  or  lithaemia ;  or  it  accompanies  anaemia, 
or  follows  long-continued  and  exhausting  discharges. 

Vertigo  may  attend  any  disorder  of  the  brain.  The  cerebral 
form  is  recognized  in  part  by  the  absence  of  those  affections  of 
other  organs  which  would  induce  the  dizziness, — and  among  tliese 
we  must  not  forget  eye-strain  and 'local  palsies  of  the  muscles  of 
the  eyeball, — in  part  by  its  being  joined  to  an  almost  constantly 
present  sense  of  uncertainty  in  movement,  to  headache,  and  to 
further  signs  of  an  encephalic  malady.  Moreover,  it  is  usually 
objective  in  character  :  surrounding  objects  appear  to  the  patient 
to  move,  not  he  himself;  and,  unlike  the  subjective  vertigo  so 
common  in  mere  sympathetic  disturbance  of  the  brain,  closing 
the  eyes  relieves  it. 

The  most  common  form  of  vertigo,  not  arising  from  brain 
affection,  is  the  so-called  stomachal  vertigo.  It  is  apt  to  come  on 
in  paroxysms,  sometimes  in  the  middle  of  the  night  or  in  the 
early  morning,  and  is  associated  with  a  dull,  heavy  ache  in  the 
head,  and  with  more  or  less  gastric  disturbance,  often  following 
indiscretion  in  diet.  Yet  the  tongue  may  be  clean,  and  the  diges- 
tive disorder  so  slight  that  it  is  only  by  the  after-symptoms,  by 
the  relief  afforded  by  attention  to  diet,  and  by  remedies  acting  on 
the  digestion,  that  we  clearly  make  out  the  cause  of  the  vertigo. 
Between  the  attacks  the  patient  is  free  from  the  affection ;  though 
there  are  cases  of  more  chronic  kind,  in  which  a  certain  amount  of 
giddiness  is  present  for  long  periods  with  only  comparatively  short 
intervals  of  freedom.  Here  food  and  stimulus  are  apt  to  relieve 
the  giddiness,  which  exists  often  with  symptoms  not  of  violent 
indigestion,  but  of  delayed  and  slow  digestion,  and  may  become 
aggravated  into  a  severe  attack  if  the  stomach  be  for  a  long  time 
empty.  In  the  gastric  vertigo  there  is  no  loss  of  consciousness. 
The  pathology  is  obscure.  Woakes  *  has  endeavored  to  establish 
a  direct  nervous  communication  between  the  stomach  and  the 
labyrinth  to  explain  the  vertigo.  Others  -regard  the  irregularity 
in  the  cerebral  circulation  produced  by  the  gastric  disorder,  an- 
aemia or  hyperemia,  as  the  cause. 

*  Deafness,  Giddiness,  etc.,  1879. 


74  MEDICAL    DIAGNOSIS. 

Another  form  of  vertigo  of  eeeentrie  origin  is  that  associated 
witli  partial  deafness  or  ringing  in  the  cars.  Again,  there  may  be 
an  alfeetion  of  the  internal  ear,  the  semicircular  canals  of  the  laby- 
rinth especially  being  the  seat  of  an  intlamination,  and  the  vertigo 
set  in  suddenly.  Its  onset  is  apt  to  be  associated  ^vith  vomiting, 
with  suddenly-developed  tinnitus,  with  pain  produced  in  the 
affected  ear  by  the  slightest  noise,  and  with  symptoms  of  apoplexy 
or  a  fainting  condition.  Such  cases,  to  which  Meniere  particularly 
has  called  attention,  at  times  very  speedily  terminate  fatally.  But 
the  acute  seizure,  which  is  by  far  the  most  common  beginning  of 
the  auml  vertigo,  may  leave  behind  giddiness  and  a  persistent 
unsteadiness  in  standing  and  walking,  or  a  tendency  to  go  for- 
ward or  backward,  or  a  reeling  gait,  which,  with  the  intense 
vertigo,  the  vomiting,  the  persistent  noises  in  the  ears,  the  unim- 
paired consciousness,  and  the  deafness,  become  very  valuable  signs 
of  jMeniere's  disease.  The  deafness  shows  especially  in  defect  of 
power  of  hearing  vibration  conducted  through  the  skull.  It  is 
often  one-sided,  generally  on  the  side  of  the  marked  tinnitus,  and 
never  absolute.  Again,  it  may  be  noticed  that  there  is  deafness 
for  certain  groups  of  musical  sounds,  which  Knapp  accepts  as 
proof  that  the  disorder  has  extended  to  the  cochlea. 

In  some  instances  the  patient  has  a  tendency  to  turn  to  one  side 
or  to  walk  round  and  round  in  a  circle  ;  and  he  is  always  miser- 
able, although  his  general  health  suffers  but  little.  The  dis- 
turbance of  the  equilibrium  is  not  always  present ;  there  may  be 
disturbance  of  hearing  without  it.  The  vertigo  is  generally  the 
most  prominent  symptom  of  the  disease,  and  persistent  vertigo 
not  epileptic  in  character  or  obviously  associated  with  an  organic 
brain  affection  is  nearly  always  aural.  The  dizziness  is  very 
apt  to  be  severe,  to  come  on  in  paroxysms,  and  to  be  excited  by 
some  effort  or  movement.  It  becomes  associated  with  pallor, 
with  faintness,  with  vomiting,  and  in  part  it  remains  even  be- 
tween the  paroxysms.  During  these  the  roaring  in  the  ears  may 
or  may  not  be  increased,  but  signs  of  eye-disturbance  are  very  apt 
to  show  themselves.  The  disease  may  result  from  any  process 
that  involves  the  labyrinth  and  the  nerve-endings.  It  is  more 
common  in  men  than  in  women,  and  is  very  rare  in  young  persons. 
It  may  come  on  after  cold  and  exposure,  or  originate  in  gout  or  in 
syphilis.    All  cases  of  aural  vertigo  do  not  set  in  suddenly  ;  some 


DISEASES    OF    TPIE    BRAIN    AND    SPINAL    COUD.  7o 

are  slight,  others  are  very  severe  and  du  not  cease  until  the  hearing 
is  totally  lost.     Many  cases  progress  slowly  to  recovery. 

To  return  to  vertigo  connected  with  cerebral  or  cerebro-spinal 
disease.  There  is  a  kind  which  Trousseau  especially  has  described. 
The  abnormal  sensation  is  very  short  in  its  duration,  but  severe ; 
the  patient  momentarily  loses  all  consciousness.  The  vertigo  recurs 
at  uncertain  times  :  while  actively  engaged,  sometimes  while  in  bed 
and  half  asleep.  The  head  feels  heavy  after  an  attack,  and  the 
mind  is  temporarily  stupefied  ;  otherwise  the  health  is  good.  Tliis 
type  of  vertigo  is  dangerous.  It  is  often  the  'precursor  of  epilepsy, 
and  after  a  time  becomes  associated  with  convulsions. 

Another  kind  of  vertigo  is  that  which  arises  from  ovenoork  of 
the  brain.  At  times  giddiness  is  the  only  symptom  of  disorder, 
essential  vertigo,  and  is  present  for  many  years,  the  patient  enjoy- 
ing otherwise  excellent  health.  I  have  known  a  number  of  such 
instances  in  which  the  tendency  appeared  to  have  been  inherited. 
If  it  do  not  break  out  until  late  in  life,  it  is  a  matter  of  more 
serious  concern. 

In  laryngeal  vertigo^'  there  is  a  close  connection  with  epileptic 
seizures.  The  chief  symptoms  are  tickling  or  burning  in  the 
larynx,  followed  by  vertigo,  loss  of  consciousness,  and  spasmodic 
movements  in  the  face  and  limbs.  The  larynx  is  healthy ;  but  in 
a  case  observed  by  Sommerbrodt  a  polypus  existed,  the  removal 
of  which  cured  the  affection. 

Besides  headache  and  vertigo,  there  are  various  unnatural  sen- 
sations, such  as  a  feeling  of  momentary  unconsciousness  without 
giddiness ;  a  feeling  within  the  cranium  of  weight,  of  constric- 
tion ;  the  feeling  described  as  a  rush  of  blood  to  the  head ;  ocular 
spectra,  and  other  false  perceptions  of  many  kinds  and  of  every 
gradation.  But  I  shall  do  no  more  than  advert  to  this  subject, 
and  shall  now  consider  some  of  the  morbid  phenomena  of  the 
special  senses,  particularly  of  the  senses  of  sight  and  hearing. 

DERANGEMENT    OP    SPECIAL    SENSES. 

Vision. — The  sense  of  vision  may  be  exalted,  impaired,  or  per- 
verted in  disorders  of  the  brain,  Avhether  organic  or  functional. 
It  is  exalted  in  inflammation  ;  impaired,  even  totally  lost,  in  soft- 

*  Gasquet,  Practitioner  for  August,  1878;  Charcot,  Progres  Medical,  No. 
17,  1879. 


76  MEDICAL    DIAGNOSIS. 

ening,  in  tumor.s,  in  aj)o|)lexy,  and  duriuo;  violent  hysterical  at- 
tacks simulating  apoplexy.  Perversions  of  the  sense  of  vision 
are  more  fretjuent  than  its  abolition,  and  probably  more  j)eenliar 
to  cerebral  atfeetions.  They  are  of  all  kinds, — some  of  great  eon- 
sequence,  others  of  but  little,  lluscse  volltantc'^,  or  the.  appear- 
ance of  spots  and  various  small  objects  floating  before  the  eye, 
have  the  latter  significance  ;  for  they  may  happen  in  almost  any 
form  of  cerebral  disturbance,  also  in  anaemia,  in  cardiac  maladies, 
in  the  neuroses,  and  in  states  of  nervous  exhaustion.  They  are 
simply  the  shadows  of  vitreous  opacities  or  retinal  vessels  upon 
the  retina,  and  have  nothing  to  do  with  anything  but  the  local 
condition,  which  is  without  significance.  Of  other  manifesta- 
tions of  deranged  sight,  such  as  illusions,  ocular  spectra,  and 
phantasms,  I  shall  only  state  that  they  are  more  common  in  sick 
headache,  and  in  derangement  of  the  mind,  temporary  or  per- 
manent, than  in  I'ecognizable  organic  disease  of  the  brain.  Yet 
they  are  found  in  affections  of  certain  parts  of  the  brain  ;  for  in 
disease  of  the  posterior  lobes,  as  Hughlings  Jackson  has  observed, 
colored  vision  and  optical  illusions  are  frequent. 

The  appearance  of  the  eye  is  often  of  as  much  significance 
as  the  derangement  of  sight.  In  some  cerebral  maladies  the  eye 
has  a  fixed  stare ;  in  others  the  eyelids  are  constantly  moving : 
but  the  latter  is  a  sign  more  frequent  in  chorea,  local  spasm,  and 
hysteria.  Great  brilliancy  of  the  eye  is  often  noticed  in  menin- 
gitis and  in  insanity. 

Derangements  of  the  ocular  mechanism  may  be  the  result  of 
remote  causes,  or,  themselves  primary,  may  become  the  starting- 
point  of  disorder  elsewhere.  In  the  first  case  their  study  is  val- 
uable to  the  general  diagnostician  as  indicative  of  the  seat,  nature, 
or  stage  of  many  diseases  in  other  parts  of  the  system  ;  in  the 
second  case  the  diagnosis  as  Avell  as  the  therapeutics  of  the  dis- 
tant and  related  disease  is  dependent  upon  the  appreciation  of  the 
ocular  derangement.  It  thus  becomes  evident  that  both  semeio- 
logically  and  therapeutically  the  abnormalities  of  the  visual  mech- 
anism are  of  the  highest  importance  in  many  systemic  affections, 
particularly  in  disease  of  the  cerebro-spinal  system,  where  it  is 
almost  always  necessary  to  inquire  as  to  derangements  of  the 
eyes  and  their  significance. 

Let  us  first  briefly  consider  the  idiopathic  derangements  of  the 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  77 

eye  that  induce  derangements  elsewhere.  Both  in  origin  and  in 
result  these  are  essentially  functional.  So  far  as  relates  to  the 
eye  they  consist  chiefly  either  in  abnormalities  of  refraction,  classed 
under  the  general  head  of  ametropia,  and  comprising  hyperopia, 
astigmatism,  myopia,  and  presbyopia,  singly  or  combined ;  or  in 
incoordination  of  the  external  ocular  muscles,  commonly  called 
insufficiency.  The  results  of  ametropia  and  muscular  insufficiency 
are  conveniently  called  eye-strain;  and  the  symjitoms  of  these 
conditions  must  not  be  neglected  by  the  physician,  especially  in 
view  of  the  fact  that  eye-strain  generally  evinces  itself  not  so 
much  in  ocular  or  visual  symptoms  as  in  functional  nervous 
derangements  often  far  removed  and  apparently  disconnected. 
For  example,  it  is  a  well-established  fact  that  eye-strain  is  prone 
to  produce  headache,  especially  in  young  women  after  the  age 
of  puberty.  These  headaches  are  usually  frontal,  but  may  also 
be  occipital,  less  frequently  of  the  vertex  or  diffused.  There 
is,  moreover,  good  reason  for  believing  that  eye-strain  may  be 
the  starting-point  of  choreic  symptoms,  and  even  of  genuine 
chorea.  Cases  have  been  reported*  by  trustworthy  observers 
showing  that  the  same  cause  may  produce  functional  gastric 
derangements,  hysteria,  melancholia,  and  even  epilepsy.  The 
lesson  is  obvious  that  when  these  or  other  functional  affections 
do  not  yield  to  direct  treatment,  or  wlien  their  origin  is  not 
otherwise  explainable,  we  should  at  once  proceed  to  exhaust  the 
possibilities  of  a  reflex  neurosis  due  to  ocular  abnormality  or  to 
some  other  peripheral  irritation. 

Hyperopia  and  hyperopic  astigmatism  are  much  the  most 
frequent  sources  of  eye-strain,  and  by  the  aid  of  a  mydriatic, 
followed  by  tests  with  the  trial-lenses,  the  diagnosis  of  the  ex- 
istence and  amount  of  the  defect  may  be  made.  In  the  neu- 
rotic, or  in  those  with  intercurrent  affections  and  weaknesses, 
the  smallest  amount  may  become  the  source  of  irritational  strain. 
Muscular  insufficiency  is  the  next  most  frequent  cause  of  ocular 
irritation,  and  its  existence  is  at  once  and  easily  detected  by  a 
simple  test.  The  correct  diagnosis  of  its  amount  demands  the 
offices  of  one    specially  skilled.      Simple    myopia   produces   no 


*  For  example,  Clinical  Illustrations  of  Reflex  Ocular  Neuroses,  by  Gould, 
Amer.  Journ.  Med.  Sci.,  January,  1890. 


78  MEDICAL    DIAGNOSIS. 

strain,  1)ut  myopic  astigmatism,  and  presbyopia,  may  sometimes 
cause  it. 

Turning  now  to  the  consideration  of  those  changes  in  the  ocular 
mechanism  which  indicate  effects  and  symptoms  of  disease  elsewhere, 
we  find  that  disease  in  ahnost  any  part  of  the  organism  may 
give  indications  of  its  nature  and  location  in  the  eves.  These 
symptoms,  either  singly  or  combined,  are  of  a  tlireefold  nature  : 

Changes  in  the  external  appearances  and  visible  to  the  naked 
eye. 

Changes  in  the  fundus  oculi,  or  eye-ground,  as  revealed  by  the 
ophthalmoscope. 

Defects  of  vision  as  shown  by  the  subjective  report  of  the 
patient. 

The  first  and  last  set  of  symptoms  require  no  very  considerable 
special  training  to  study,  but  the  use  of  the  ophthalmoscope  does 
demand  it,  and  often  to  such  a  degree  that  many  are  unfortunately 
compelled  to  forego  a  source  of  knowledge  that,  either  positively 
or  negatively,  is  never  without  use. 

I.  Among  the  external  ocular  abnormalities  of  the  eyes  visible 
to  the  examiner,  exception  must  of  course  first  be  made  of  such 
local  diseases  as  have  no  systemic  relations,  such  as  ecchymoses, 
congestions  or  inflammations  of  the  lids  and  conjunctiva,  trachoma, 
glaucoma  (with  an  unusual  hardness  and  anaesthesia  of  the  eye- 
ball, impaired  vision,  dilated  pupil,  etc.),  cataract,  congenital 
anomalies,  etc.  Herpes  zoster  ophthalmicus,  a  peripheral  neu- 
ritis of  the  ophthalmic  branch  of  the  fifth  nerve,  is  a  dangerous 
and  painful  malady,  often,  if  not  always,  owing  to  local  causes. 
Exophthalmos  is  either  due  to  local  disease  or  is  present  as  one 
of  the  three  symptoms  of  the  affection  called  exophthalmic  goitre. 
A  late  case*  seems  to  locate  the  focal  lesion  in  the  medulla,  in 
the  central  part  of  the  floor  of  the  fourth  ventricle,  near  the 
nucleus  of  the  sixth  nerve. 

Next  in  importance  is  a  class  of  diseases  due  to  external  in- 
fection that  generally  points  to  a  source  of  contagion  elsewhere  in 
the  organism.  Cases  of  localized  tuberculosis  of  the  conjunctiva 
have  been  reported  wherein  the  handkerchief  has  perliaps  carried 
the  bacillus  to  the  eye.     Gonorrhoeal  ophthalmia  is  a  constantly 

*  Hale  White,  Brit.  Med.  Journ.,  March  30,  1889. 


DISEASES    OF    THE    BRAIN    AND    SPINAE    CORD.  79 

recurring  disease  in  oplithalinic  practice ;  but  the  most  frequent 
and  frightful  is  the  ophthahiiia  of  the  new-born, — ophthahnia 
neonatorum, — due  to  infection  during  labor  with  the  vaginal  dis- 
charges of  the  mother.  It  is  said  that  the  greater  part  of  the 
blindness  of  the  world  is  due  to  this  wholly  preventable  disease. 

Affections  of  the  conjunctiva  or  lids  may  have  their  origin  in 
diseases  of  the  adjacent  skin  or  mucous  membrane,  and  extend  to 
the  eyes  by  simple  contiguity  of  structure.  There  is  reason  to 
believe  that  a  close  connection  may  frequently  exist  between  hay- 
fever,  catarrhal  and  other  diseases  of  the  nasal  mucous  membrane, 
and  similar  conditions  of  the  conjunctiva, 

Arcus  senilis,  a  ring  of  grayish  tissue-change  about  the  corneal 
limbus,  betokens  generalized  atheromatous  or  fatty  degeneration, 
arterial,  cardiac,  etc.  Interstitial  or  diffuse  keratitis  is  nearly 
always  the  result  of  inherited  syphilis.  In  rubeola,  scarlatina, 
smallpox,  and  erysipelas,  the  external  ocular  structures  may  be 
injured  or  destroyed  by  the  same  causes  that  produce  the  skin- 
lesions,  or  by  extension  of  the  disease  to  the  eyes  from  the  skin. 

Of  the  remaining  affections  of  the  external  parts  of  the  eye 
indicative  of  general  or  internal  disease,  the  most  important  are 
those  pertaining  to  the  muscles  of  the  eye  or  movements  of  the 
globe.  They  easily  fall  into  two  groups, — those  of  the  external 
and  those  of  the  internal  muscles. 

Strabismus,  or  squint,  may  be  due  to  local  causes,  such  as  in- 
juries, or  cold,  etc.,  but  it  usually  arises  from  a  lack  of  equal  or  bal- 
anced power  among  the  twelve  external  muscles,  and  to  ametropia 
and  anisometropia.  The  distinctive  subjective  characteristic  of 
squint  is  double  vision  ;  but  so  numerous  are  the  possible  combi- 
nations that  it  is  often  difficult,  if  not  impossible,  to  tell  just  what 
nerves  or  muscles  are  implicated,  and  the  exact  seat  of  the  lesion. 
In  examining  for  strabismus  we  observe  whether  the  eyeball  is 
turned  inward  or  outward.  In  paralysis  of  the  external  rectus 
we  have  ordinarily  an  internal  or  convergent  squint,  in  paralysis  of 
the  internal  rectus  an  external  or  divergent  strabismus.  In  palsy 
of  the  superior  rectus  there  is  inability  to  raise  the  eyeball  in  a 
proper  manner  above  the  horizontal  level ;  inability  to  lower  it 
below  indicates  palsy  of  the  inferior  rectus.  Strabismus  due  to 
local  causes  must  be  distinguished  from  true  paralytic  squint  due  to 
more  centrally  located  lesions.    It  must  also  be  distinguished  from 


80  MEDICAL   DIAGNOSIS. 

spastic  action  of  the  niusclcri  caused  by  irritatioiuil  intracranial 
injuries.  In  both  the  latter  cases  there  is  a  conjugate  or  common 
movement  of  both  eyes  to  one  side  or  to  the  other,  called  conjagate 
lateral  deviation.  In  spastic  irritational  lesions  of  the  cortex  the 
eyes  are  turned  from  the  side  of  the  injury ;  in  paralytic  or  de- 
structive lesions  they  are  turned  toward  it.  The  eyes,  as  it  has  been 
said,  look  at  the  lesion  in  paralysis,  away  from  it  in  spasm,  Tiie 
symptom,  however,  owing  to  its  frequently  temporary  existence, 
and  also  to  the  fact  that  it  may  arise  as  an  indirect  symptom, 
must  not  be  relied  upon  except  in  conjunction  with  others  and 
wlien  continuing  at  least  for  several  weeks.*  The  seat  of  the 
lesion  may  be  in  the  cortex,  the  internal  capsule,  or  tlie  pons ; 
in  the  latter  case  the  symptoms  are  direct  and  the  deviation 
of  the  eyes  is  the  reverse  of  that  given  above  :  the  eyes  in  paral- 
ysis look  away  from  the  lesion ;  in  spasm,  toward  it.  If  in 
lesions  of  the  pons  the  sixth  nerve  nucleus  is  included,  there  is, 
of  course,  paralysis  of  the  external  rectus,  so  that  the  correspond- 
ing eye  cannot  be  rotated  outward  past  the  middle  line,  whilst 
the  other  eye  cannot  be  rotated  inward  past  the  middle  line.  This 
associated  movement  of  the  other  eye  will  not  be  impaired  if  the 
injury  to  the  sixth  nerve  be  between  the  nucleus  and  the  globe. 

Owing  to  the  jieculiar  position  of  its  nucleus  and  the  long 
course  of  exit  of  the  sixth  nerve,  its  exclusive  paralysis  alone  is 
the  most  frequent  of  single  nerve  paralyses.  It  is  peculiarly 
liable  to  paralysis  from  indirect  or  pressure  causes,  but  if  con- 
nected with  paralysis  of  the  opposite  side  of  the  body  and  other 
symptoms  of  brain  disease,  it  clearly  points  to  a  lesion  of  the 
pons.  Owing  to  the  close  topographical  relations  of  their  nu- 
clei, paralyses  of  the  sixth  and  facial  nerves  are  frequently  asso- 
ciated. Other  nerves  originating  in  the  pons  are,  of  course,  liable 
to  implication  in  varying  degrees.  Next  to  the  sixth  the  third 
nerve  is  the  most  frequently  paralyzed,  and,  in  proportion  to  the 
numbers  of  twigs  involved  and  the  completeness  of  their  paraly- 
sis, there  is  a  probability  of  a  lesion  at  the  base  of  the  brain, 

*  The  direct  symptoms  are  those  intimately  dependent  upon  the  lesion  of  a 
part ;  the  indirect  or  distant  symptoms  are  those  due  to  disturbances  of  circula- 
tion, to  pressure,  to  the  reflex  or  inhibitory  effects  at  other  points  than  the  seat 
of  injury.  The  less  raai-ked  the  cerebral  symptoms,  the  more  probable  is  it 
that  the  paralyses  are  direct. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COIID,  81 

though  the  location  may  be  rendered  certain  only  by  a  study 
of  other  associated  paralyses  and  symptoms. 

Ptosis  may  exist  either  with  or  without  involvement  of  other 
third-nerve  branches,  but  in  any  case  the  value  of  tlie  droop  of  the 
upper  eyelid  as  a  localizing  symptom  is  somewhat  indeterminate. 
If  of  one  eye  alone,  ptosis  usually  indicates  a  cortical  lesion, 
unless  due  to  evidently  local  causes.  In  paralysis  of  the  tliird 
nerve  we  have,  besides  the  ptosis,  dilatation  of  the  pupil  of  mod- 
erate extent.  Inability  to  close  the  eyelids  is  associated  with 
paralysis  of  the  facial  nerve. 

As  regards  the  nature  of  the  lesion,  the  ocular  symptoms  gen- 
erally give  little  definite  indication,  and,  at  all  events,  must  be 
considered  in  relation  with  others  and  with  the  history  of  the  case. 

AbnormoMties  of  the  pupil  are  understood  by  remembering  that 
the  third  nerve  controls  the  contractile  mechanism  and  the  cer- 
vical sympathetic  the  dilating  mechanism.  Hence  an  unusual 
diminution  or  increase  of  either  innervation,  especially  of  the 
first,  causes  alterations  of  the  pupil  at  once.  Irritative  cerebral 
lesions  thus  produce  contraction,  whilst  lesions  which  destroy  cere- 
bral function  produce  morbid  dilatation.  The  state  of  the  pupil 
in  tumors,  hemorrhage,  and  inflammatory  conditions  of  the  brain 
may  thus  furnish  us  with  most  serviceable  indications  of  the  ex- 
tent and  destructiveness  of  the  injury.  When  but  one  pupil  is 
abnormal,  the  rule  above  given  serves  to  indicate  lesion  of  the 
corresponding  half  of  the  cerebrum,  irritational  or  paralytic  ac- 
cording to  the  degree  of  the  injury.  Yet  one-sided  contrac- 
tion, like  one-sided  dilatation,  may  also  be  owing  to  tumors  at 
the  root  of  the  neck.  Hemorrhage  or  effusion  into  the  pons  or 
lateral  ventricles,  when  small  or  irritative,  produces  contraction  ; 
but  if  large,  permanent  dilatation.  Certain  drugs,  such  as  opium, 
contract  the  pupil ;  belladonna  and  chloral  dilate  it.  We  also 
find  dilatation  of  both  pupils  in  chlorosis  and  in  lesions  of  the 
upper  portion  of  the  spinal  cord.  If  the  foot  be  pricked,  the 
pupils  at  once  dilate,  provided  the  iris  be  uninjured  and  the  sen- 
sory columns  be  intact.  In  epileptics  this  reflex  excitability  is 
greatly  diminished.*  The  pupillary  reaction  to  light  may  some- 
times be  useful  in  diagnosticating  the  location  of  a  lesion,  whether 


*  Lawson,  West  Eidiug  Eeports,  vol.  iv. 
6 


82  MEDICAL    DIAGXOSIS. 

bovond  the  corpora  qnaclrig-oiiiina  or  not.  If  beyond,  the  })upil- 
larv  reflex  will  be  retained,  de-sjiite  the  loss  of  sight.  Lesions 
of  the  spinal  cord  and  s}'m pathetic  prodnce  resnlts  the  reverse  of 
the  preceding-.  Iri'itative  lesions  dilate,  paralytic  lesions  contract. 
In  this  connection  the  phenomenon  called  the  Argyll-lvobertson 
pupil — the  light-reflex  lost,  the  acconunodative  reflex  retained, 
of  a  myotic  pnpil — is  of  value  as  indicating,  often  early,  scle- 
rosis of  the  posterior  columns  of  the  cord.  Paralysis  of  the 
accommodation  may  exist  independent  of  pupillary  involvement, 
and  its  significance  is  that  of  paralysis  of  other  branches  of  the 
third  nerve. 

II.  Abnormal  changes  in  the  fundus  of  the  eye  may  be  of  great 
diagnostic  value,  and  in  almost  every  case  of  circulatory  or  nervous 
disease  the  routine  use  of  the  ophthalmoscope  would  give  valuable 
hints  of  general  disorder.  This  is  rendered  exceptionally  true 
by  the  fact  that  these  changes  are  most  frequently  symptomatic, 
and,  with  few  exceptions,  do  not  arise  from  local  disease. 

We  should  invariably  examine  with  the  ophthalmoscope  the 
eyes  of  patients  suspected  of  having  disease  of  any  part  of  the 
cerebro-spinal  nervous  system.  Changes  in  the  eye,  indeed,  often 
occur  early  enough  to  be  the  first  certain  sign  of  disease,  and 
this,  too,  without  any  impairment  of  sight ;  on  the  other  hand, 
lesions  indicating  cerebral  or  other  organic  affection  have  been 
found  in  cases  in  which  failure  of  sight  was  alone  complained 
of,  the  cause  being  unsuspected.  But  particularly  is  the  ophthal- 
moscope valuable  in  enabling  us  to  differentiate  organic  from 
functional  affections.  It  tells  us  of  extension  of  congestion  or  of 
inflammation  of  the  brain  to  the  internal  structures  of  the  eye, 
or  of  the  amount  of  resistance  offered  to  the  circulation  within 
the  cranium.  This  resistance  may  either  arise  from  a  marked 
"  coarse"  lesion,  or  may  make  itself  felt  through  the  sympathetic 
nervous  system. 

The  changes  in  connection  with  organic  disease  have  been  ob^ 
served  chiefly  in  the  retina,  the  optic  disk,  and  the  choroid.  In 
using  the  ophthalmoscqpe  for  medical  diagnosis  we  pay  particular 
attention  to  these  structures;  especially  do  we  note  the  disk,  its 
color  and  size,  and  the  pigment  around  its  edges,  the  region  of 
the  macula,  the  size  and  appearance  of  the  arteries  and  veins, 
whether    diminished,   enlarged,   or    tortuous,   whether   there   are 


DISEASES    OF    THE    BRAIN    AND   SPINAL    CORD.  83 

exudations  or  hemorrhages  in  the  course  of  the  vessels,  and  in 
what  part  of  the  eye-ground  the  patches  are  most  marked. 

Hypersemia,  or  increased  redness,  is  due  to  local  causes  ;  and  the 
fundus-changes  in  myopia,  astigmatism,  retinitis  pigmentosa,  and 
some  forms  of  choroiditis  are  also  to  be  excepted.  In  diseasefs 
of  the  blood  and  the  blood-making  organs,  the  indications  are  re- 
markably clear.  Retinal  hemorrhages  are  a  common  concomitant 
of  such  general  diseases  as  albuminuria,  diabetes,  anaemias,  cardiac 
valvular  disease,  arterial  atheromatous  and  fatty  degenerations, 
chronic  malaria,  and  other  febrile  conditions.  Embolism  of  the 
central  artery  of  the  retina,  causing .  unilateral  blindness,  points 
to  cardiac  valvular  disease.  There  is  a  grayish  discoloration 
about  the  macula,  with  a  central  cherry-red  spot.  Poverty  of 
the  blood,  simple  ansemia,  is  at  once  recognized  by  the  trans- 
parency of  the  blood-columns,  and  leuksemia  and  pernicious  an- 
semia  produce  characteristic  changes  in  the  eye-ground,  especially 
the  last.  Math  retinal  oedema  and  hemorrhages,  disk -discoloration, 
arterial  pallor,  and  venous  distention.  Albuminurie  retinitis  is 
not  invariable  in  albuminuria,  but,  when  present,  renders  the 
prognosis  more  serious.  The  typical  fundus-changes  consist  in 
an  early  stage  of  haziness  of  the  papilla  and  central  part  of  the 
fundus,  slight  hemorrhages,  and  faint  grayish  discolorations. 
Later,  white  dots  or  splotches  are  grouped  about  the  macula,  or, 
flame-like,  radiate  from  it.  Striate  hemorrhages  are  scattered 
over  the  fundus,  the  papilla  is  oedematous,  and  its  limits  are 
obscured.  The  ophthalmoscopic  signs  of  diabetic  retinitis  are 
very  similar  to  the  last.  Visual  disturbances,  however,  do  not, 
in  either  case,  stand  in  any  exact  ratio  to  the  defects  of  the  eye- 
ground. 

'Atrophy  of  the  optic  nerve,  recognizable  by  the  whiteness  or 
discoloration  of  the  disk,  failure  of  vision,  even  to  blindness,  etc., 
may  sometimes  seem  to  have  no  remote  causes,  but  is  commonly 
associated  with,  or  a  result  of,  diseases  or  lesions  of  the  spinal 
cord  or  the  brain,  toxic  substances  in  the  blood,  papillitis,  etc. 

Papillitis,  optic  neuritis,  "  choked  disk,"  is  a  symptom  of  most 
decided  diagnostic  value.  The  picture  is  easily  recognized,  con- 
sisting in  a  swollen  red  disk,  the  edges  and  vessels  of  which  are 
obscured  by  a  "  woolly,"  striate  blurring  extending  to  the  adja- 
cent retina.     This  condition  is  always  symptomatic,  and  in  the 


84  MEDICAL   DIAGNOSIS. 

laroG  majority  of  cases  of  tumor  of  the  brain,  althouiili  other  in- 
tracranial diseases  may  produce  it.  From  pai)illitis,  however, 
nothing  may  be  argued  as  to  the  nature  or  location  of  the  tumor 
or  other  aifection.  Its  existence — and  it  is  often  not  a  late  symp- 
t(Mn — at  once  demands  careful  inquiry  and  energetic  treatment. 
Tliis  is  particularly  true  because  unimpaired  vision  may  coexist 
with  even  a  severe  papillitis. 

Choroidal  infammcdions  are  chiefly  distinguishable  by  the 
striking  color  and  pigment  changes  of  the  fundus.  Plastic  cho- 
roiditis is  commonly  secondary  to  meningeal  alFections  and  pros- 
trating fevers ;  purulent  choroiditis,  to  local  or  general  infection 
or  septica?nna.  Disseminated  and  central  choroiditis,  or  choroido- 
retinitis,  is  frequently  the  result  of  syphilis.  The  choroid  is 
peculiarly  liable  to  become  the  seat  of  tuberculous  growths. 

III.  Passing  now  to  tlie  consideration  of  purely  .stibjccfive  visual 
derangements,  it  becomes  highly  necessary  to  determine  first  whether 
such  defects  arc  due  to  refraction-errors,  insufficiencies,  and  other 
local  causes,  or  if  they  are  secondary  and  symptomatic.  Unless 
other  indications  are  present,  the  complaint  of  headache,  especially 
if  frontal,  weariness  or  pains  of  the  eyes  after  near-work,  aifec- 
tions  of  the  lids  and  conjunctiva,  conjoined  with  general  irri- 
tability and  functional  gastric  derangements,  almost  invariably 
indicate  eye-strain  as  primary.  Simple  inability  to  see  distant 
objects  clearly,  without  other  symptoms  local  or  general,  indicates 
myopia.  Tobacco  amblyopia,  due  to  the  excessive  indulgence  in 
tobacco  or  alcohol,  has  but  a  single  objective  sign  :  an  unusual 
])allor  of  the  temporal  portion  of  the  papilla.  There  is  deteriora- 
tion of  visual  acuity,  to  which  subnormal  color-perception  may  be 
added.  Marked  visual  deterioration  of  a  single  eye  should  lead 
to  inquiry  for  extra-local  causes.  Wlicn  ametropia  has  been  ex- 
cluded and  the  above-described  ophthalmoscopic  signs  are  wanting, 
the  cause  must  be  sought  in  disease  of  other  organs.  Paresis,  and 
even  paralysis  of  the  accommodation,  and  visual  failure,  are  not 
infrequent  as  reflex  neuroses  from  peripheral  irritation  of  other 
parts.  Cases  of  abnormalities  of  dentition  and  other  dental 
troubles  producing  such  visual  defects  have  been  frequently  re- 
ported. Menstrual  difiiculties,  masturbation,  the  influence  of 
pregnancy  and  lactation,  may  sometimes  account  for  obscure 
ocular  troubles.     Hemeralopia,  night-blindness,  due  to  deficient 


DISEASES   OF   THE   BRAIN   AND   SPINAL   CORD.  85 

nutrition  of  the  general  system,  has  been  traced  to  insufficient 
food.* 

The  most  important  ocular  sign  of  cerebral  disease,  and  one 
invariably  pointing  to  intracranial  affections,  is  hemianopsia,  or 
loss  of  vision  of  the  halves  of  the  fields.  The  most  common 
variety  is  that  called  homonymous  lateral  hemianopsia,  in  which 
the  loss  is  either  of  the  temporal  half  of  one  eye  and  of  the  nasal 
half  of  the  other,  or  vice  versa,  a  vertical  line  nearly  through  the 
centre  being  the  dividing  line.  There  are  three  other  forms  of 
hemianopsia,  called  temporal,  nasal,  and  altitiidinal,  in  which  the 
half-fields  are  respectively  the  two  temporal,  the  two  nasal,  with 
the  dividing  line,  as  previously,  perpendicular,  or  the  two  dark 
half-fields  are  the  upper  or  the  lower  halves,  with  the  dividing 
line  horizontal.  These  three  varieties  are  seldom  met  with,  and, 
from  the  peculiar  anatomical  relations  of  the  optic  chiasm  or 
commissure,  are  readily  recognized  as  the  results  of  lesions  of 
this  part,  either  at  one  side  or  the  other,  above  or  below.  Ho- 
monymous lateral  hemianopsia  always  indicates  lesion  beyond 
the  chiasm.  If  the  hemianopsia  is  "  relative," — involves  only 
a  part  of  the  perceptions  of  light,  form,  and  color,  the  three  con- 
stituent factors  of  ordinary  vision,  and  believed  to  have  special 
subcentres  or  strata  in  the  general  visual  centre, — it  must  neces- 
sarily proceed  from  a  partial  lesion  of  the  common  visual  centre 
situate  in  the  cuneus  of  the  occipital  lobe.f  But  if  the  hemi- 
anopsia is  absolute, — with  complete  loss  of  light,  form,  and 
color  sense, — the  lesion  may  be  either  one  affecting  the  entire 
visual  centre  of  one  side,  or  one  rendering  wholly  functionless 
the  fibres  of  one  radiation,  internal  capsule,  or  optic  tract.  If 
the  latter  were  the  case  there  would  almost  certainly  be  other 
intercurrent  or  general  symptoms,  such  as  paralysis  of  other  cra- 
nial nerves,  hemiansesthesia,  some  form  of  aphasia,  or  hemiplegic 
symptoms.  A  symptom  of  great  value  in  locating  the  lesion  of 
hemianopsia  is  the  hemiopic  pupil.  Convergence  of  a  narrow 
cone  of  light  upon  the  insensitive  half  of  the  retina  yields  no 
pupillary  reflex  if  the  lesion  be  in  the  optic  tract :  if  the  pupil, 

*  See  ai'ticle  by  Kubli,  Archiv  fiir  Augenheilk.,  June,  1887,  who  describes 
three  hundred  and  twenty  cases  occurring  during  the  Kussian  church-fasts. 

f  Seguin  limits  the  centre  to  the  cuneus ;  Nothnagel  makes  it  include  also 
the  posterior  portion  of  the  superior  occipital  convolution. 


86  MEDICAL    DIAGNOSIS. 

under  such  stimulus,  contract,  tlie  lesion  must  be  beyond  the 
tract.  , 

Mbid-hUndness,  physical  vision,  but  lailure  to  realize  the  psy- 
chical import  of  the  thinu;s  seen,  sometimes  a  symptom  of  gen- 
eral paralysis  and  obscure  cerebral  disease,  indicates  a  cortical 
lesion  in  the  occipital  or  occipito-temporal  lobe,  near  by  if  not 
conteiMninous  with  the  visual  centre. 

Hearing. — As  regards  the  sense  of  hearing,  the  same  may  be 
said  as  ot"  visi(.)n.  It,  too,  is  perverted  and  impaired  in  various 
cerebral  affections.  Yet,  to  be  certain  that  the  cause  of  the  diffi- 
culty is  cerebral,  the  ear  must  first  be  examined  with  reference  to 
any  physical  im]ierfcction ;  and  in  doing  so  we  may  by  means  of 
the  otoscope  get  an  idea  of  the  vascularity  of  the  drum,  and  be 
led  from  this  to  infer  the  condition  of  the  vessels  of  the  brain. 

Great  acutencss  of  hearing  and  intolerance  of  sound  are  gen- 
erally symptoms  of  extreme  nervous  irritability,  or  of  beginning 
cerebral  inflammation.  Deafness  may  be  owing  to  softening  of 
portions  of  the  brain  ;  but  Ferrier  tells  us  that  it  is  not  met  with 
in  destructive  lesions  of  the  cortex.  Deafness  is  also  found  as  a 
temporary  and  by  no  means  unfavorable  symptom  in  the  continued 
fevers.  Imaginary  sounds  and  ringing  noises  in  the  ear,  or  tinnitus 
annum,  are  frequent  accompaniments  of  cerebral  disorders.  But 
the  latter  is  encountered  in  so  many  different  conditions — in  dis- 
eases of  the  cerebral  vessels,  in  congestion  of  the  brain,  in  Me- 
niere's disease,  in  affections  of  the  heart,  in  anaemia — that  it  is  a 
sign  of  little  moment ;  and,  in  truth,  its  most  usual  cause  is  local, 
— namely,  an  accumulation  of  wax  in  the  meatus. 

DERxlNGED   REFLEXES. 

Derangement  of  the  reflex  action  plays  a  most  important  part 
in  the  study  of  diseases  of  the  nervous  system.  Each  action  is 
brought  about  by  a  sensory  nerve  that  conveys  the  impression  to 
the  centre,  by  a  motor  nerve  that  transmits  the  impulse  from  the 
centre  to  the  periphery,  and  by  a  reflex  centre  between  the  two 
in  the  spinal  cord  connecting  the  roots  of  the  sensory  and  motor 
nerves,  which  with  them  forms  the  "reflex  arc."  The  reflex 
centre  is  to  some  extent  under  brain  control. 

There  are  two  forms  of  reflexes  to  be  especially  studied, — the 
cutaneous  or  superficial,  produced  l)y  stimulating  the  skin,  and 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  87 

the  deep  reflexes,  the  muscle  or  tendon  reflexes,  evoked  ]>y  ta})])ing 
muscles  or  tendons. 

The  superficial  may  be  almost  everywhere  excited  l^y  tickling 
or  gently  stimulating  the  skin.  The  most  usual  ones  to  he  noted 
are  the  reflex  of  the  sole  of  the  foot,  the  jjlantar  reflex  ;  and  that  of 
the  palm  of  the  hand,  the  palmar  7'eflex.  The  former,  when  nor- 
mal, attests  the  integrity  of  the  reflex  arc  at  the  lower  end  of  the 
cord;  the  palmar  reflex  indicates  a  normal  state  of  the  reflex  arc 
through  a  greater  part  of  the  cervical  enlargement.  Other  super- 
ficial reflexes  Avhich  may  be  mentioned  are  the  cremaster  reflex, 
the  drawing  up  of  the  testicle  excited  by  stimulating  the  front 
and  inner  side  of  the  thigh,  and  originating  in  the  cord  at  a  point 
between  the  first  and  second  lumbar  pairs ;  the  gluteal  reflex,  the 
contraction  caused  by  irritating  the  skin  over  the  buttock,  and 
showing  the  integrity  of  the  cord  at  the  fourth  or  fifth  lumbar 
nerve ;  the  abdominal  reflex,  a  contraction  in  the  abdominal  walls 
caused  by  scratching  the  skin  on  the  side  of  the  abdomen,  and 
depending  on  the  action  of  the  cord  from  the  eighth  to  the  t^velfth 
dorsal  nerve ;  the  epigastric,  reflex,  an  epigastric  dimpling  pro- 
duced by  stimulating  the  side  of  the  chest  in  the  fifth  or  sixth 
intercostal  space,  and  indicating  the  state  of  the  cord  from  the 
fourth  to  the  seventh  pair  of  dorsal  nerves ;  the  scapular  reflex, 
a  contraction  by  stimulation  of  the  scapular  muscles,  and  be- 
speaking the  integrity  oif  the  reflex  arc  at  the  level  of  the  upper 
two  or  three  dorsal  and  lower  two  or  three  cervical  nerves.  Other 
reflexes  of  indeterminate  utility  are  the  erector  spinse  reflex,  a 
local  contraction  of  these  muscles  produced  by  stimulation  of  the 
skin  along  their  border,  proving  that  the  reflex  arc  is  intact  in 
the  dorsal  region  of  the  cord  ;  the  palmar  reflex,  contraction  of 
digital  flexors  from  tickling  the  palm,  showing  the  cervical  region 
uninjured  ;  the  platysma  reflex,  dilatation  of  the  pupil  upon  pinch- 
ing the  platysma  myoides  muscle  ;  the  jaw-jerk  or  clonus,  elicited 
by  suddenly  depressing  the  inferior  maxilla  ;  the  peroneal  reflex,  a 
stroke  upon  these  muscles  when  in  tension,  or  when  the  foot  is  bent 
inward,  causing  a  reflex  movement.  To  these  may  be  added  the 
tendo  Achillis  reflex  or  front-tap  contraction,  described  by  Gowers, 
a  reflex  contraction  of  the  gastrocnemius  when  the  muscles  upon 
the  anterior  part  of  the  leg  are  struck,  the  leg  being  extended  and 
the  foot  flexed  by  the  hand  upon  the  sole.     It  is  considered  by 


MEDICAL    DIAGNOSIS. 


Gowors  ac3  a  delicate  tost  of  lieigbtenecl  spinal  irritability.  Among 
cranial  reflexes,  the  more  noteworthy  are  the  iris-contraction  upon 
exposure  of  the  retina  to  light;  the  eyelid-closure  from  irritation 
of  the  conjunctiva  ;  the  pharyngeal,  laryngeal,  and  palatal  reflexes 
(cough,  swallowing,  etc.)  from  irritation  of  these  parts ;  and  nasal 
reflexes,  as  in  sneezing.  The  aural  reflexes  are  of  some  value 
in  appreciating  disease  of  the  cervical  part  of  the  cord.*  In 
disease  these  superficial  reflexes  are  often  absent.  Thus,  disease 
of  ouQ  cerebral  hemisphere  diminishes  or  destroys  them  on  the 
other  side,  the  ])aralyzed  side  of  the  body. 

The  reflex  ]>henomena  connected  with  the  tendons  give  us  the 
best  illustration  of  the  so-called  deep  reflexes.  The  tendon  of  the 
patella  is  the  one  most  readily  studied  ;  and  if,  as  Wcstjibalf  and 
Erb  have  taught  us,  we  strike  abruptly  the  tendon  of  the  patella 
just  below  the  knee-cap,  after  rendering  tlie  ligamentum  patellje 
tense  by  flexing  the  knee  at  a  right  angle  while  one  knee-joint  rests 
upon  the  other,  a  sudden  contraction  takes  place  in  the  quadriceps 
femoris  muscle,  and  the  foot  is  jerked  upwards.  When  very  slight, 
the  knee-jerk  is  most  readily  elicited  by  a  tap  with  the  percussion 
hammer.  Gowers,  with  reason,  contends  that  this  reflex  is  due 
to  a  muscle  reflex  action  dependent  upon  the  spinal  cord,  and  that 
the  tendons  have  nothing  essentially  to  do  with  the  phenomenon. 
He  therefore  proposes  the  term  myodatic  contraction,  to  empha- 
size the  indispensable  condition  of  their  elicitation, — the  passive 
tension  of  the  muscle.  This  phenomenon  is  found  in  health, 
and  is  markedly  increased  in  disease  of  the  pyramidal  tract,  in 
heightened  irritability  of  the  gray  substance  of  the  spinal  cord, 
in  many  tumors  of  the  brain,  in  cerebro-spinal  sclerosis,  in  lateral 
sclerosis,  after  epileptic  seizures  or  unilateral  convulsions.^  It  is 
absent  in  locomotor  ataxia,  even  at  an  extremely  early  stage  of 
this  aiFection.  It  is  also  abolished  in  affections  of  the  anterior 
gray  cornua,  in  infantile  paralysis,  in  advanced  stages  of  pseudo- 
hypertrophic paralysis,  and,  temporarily  at  least,  as  pointed  out 
by  Hughlings  Jackson,  in  meningitis,  and  disappears  in  certain 
general  constitutional  affections,  as  in  diabetes  and  in  diphtheria.§ 


*  Amer.  Journ.  Med.  Sci.,  Dec. 

t  Archiv  fiir  P.>5ychiatrie,  Bd.  v.,  1875. 

j  Hughlings  Jackson,  Med.  Times  and  Gaz.,  Feb.  1881. 

I  Marie  et  Guinon,  Ecvue  de  Med.,  July,  1886. 


DISEASES    OP   THE    BRAIN    AND    SPINAL    CORD.  89 

I  have  also  known  it  very  exceptionally  to  be  aljsent  in  healthy 
persons,  in  one  instance  in  three  brothers. 

In  some  instances  of  disease  the  reflex  phenomena  are  produced 
on  the  side  opposite  to  the  one  acted  on.  These  crossed  reflexes 
are  not  unfrequently  met  with  in  posterior  spinal  sclerosis,  and  are 
not  merely  associated  contractions.  A  secondary  stimulation  of  a 
motor  centre  in  the  opposite  side  of  the  cord  has  been  suggested 
as  the  cause  in  a  case  of  transferred  patellar  tendon  reflex.*  A 
tap  on  the  tibia  near  its  middle  generally  induces  contractions  of 
the  quadriceps  femoris ;  and  it  is  often  followed  by  contractions  of 
the  quadriceps  of  the  opposite  leg  when  both  the  pyramidal  tracts 
are  diseased,  f 

The  phenomenon  called  reinforcement  of  a  reflex  may  have  its 
use  and  significance  in  the  diamosis  of  doubtful  or  obscure  cases. 
In  testing  the  muscular  power  of  the  hand  by  the  dynamometer,  it 
is  well  known  that  when  one  hand  is  fatigued  it  has  greater  power 
if  the  other  hand  be  forcibly  and  synchronously  clenched  than  if 
acting  alone.  In  the  same  way  it  has  been  shown  that  any  reflex 
is  heightened  by  coincident  muscular  exertion  of  other  parts  than 
those  being  tested.  Thus,  if  a  desired  reflex  be  weak  or  difficult 
to  elicit,  it  may  be  brought  out  by  muscular  tension  of  some  other 
member  or  part  of  the  body.  Strong  sensation  of  the  skin  acts 
in  the  same  way  to  reinforce  coincident  reflexes.  It  has  been 
asserted  |  that  so  slight  an  outlay  of  force  as  that  of  winking  will 
increase  the  force  of  the  knee-jerk,  if  correctly  timed.  When  the 
muscle  is  cut  off  from  connection  with  the  spinal  centres,  as  in 
the  late  stages  of  locomotor  ataxia,  the  reflex  and  any  reinforce- 
ment are  alike  impossible. 

Very  similar  to  the  knee  phenomenon  is  the  foot  phenomenon, 
or  ankle  clonus,  although  its  reflex  character  is  even  more  doubt- 
ful. Gowers,§  indeed,  has  made  it  likely  that  it  is  largely  due  to 
an  exaggerated  irritability  of  the  muscles.  It  is  produced  if  the 
foot  be  suddenly  brought  into  complete  flexion  by  the  hand  pressed 
against  the  sole,  and  still  more  readily  if  subsequently  the  tendo 

*  jVIcLane  Hamilton,  Archives  of  Medicine,  New  York,  Dec.  1883. 
f  Ross,  op.  cit.,  vol.  i. 

X  Mitchell  and  Lewis,  Tendon-  and  Muscle- Jerk,  Amer.  Journ.  Med.  Sci., 
vol.  xcii.,  1886. 

I  Medico-Chirurg.  Transact.,  1879. 


90  MEDICAL   DIAGNOSIS. 

Ac'hillis  be  quickly  tapped.  A  kind  of  convulsive  shaking  of  the 
foot  results,  dependent  on  alternate  contraction  and  relaxation  of 
the  anterior  tibial  and  calf  muscles.  Ankle  clonus  is  at  times,  not 
often,  observed  in  healthy  persons,  althoug-h  it  is  susceptible  of 
being  cultivated ;  in  lateral  sclerosis  it  is  developed  to  an  extraor- 
dinary deiTee.  Indeed,  it  is  in  excess  in  the  class  of  affections  in 
which  the  knee  reflex  is  excessive.  When  j)roduced  by  sudden 
passive  tension  alone  of  the  muscle,  it  is  indicative  of  structural 
change  in  the  spinal  cord.* 

Wrist  clonus  may  be  induced  in  the  late  rigidity  of  hemij)legia 
by  pressing  the  hand  backwards  so  as  to  produce  extreme  ext(}n- 
sion  at  the  "wrist. 

If  a  muscle  be  suddenly  relaxed,  a  slow  tonic  contraction  fol- 
lows which  may  last  for  some  minutes.  The  phenomenon  is 
best  witnessed  in  the  tibialis  anticus,  but  is  rarely  seen  in  the 
muscles  of  the  arm.  This  ixiradoxical  muscular  contraction  has 
no  definitely  ascertained  value.  It  is  sometimes  met  with  in  the 
early  stages  of  locomotor  ataxia. 

DEKANGED  MOTION". 

The  chief  manifestations  of  deranged  motion  resolve  themselves 
into  the  phenomena  called  paralysis,  ataxia,  tremor,  spasms,  and 
convulsions. 

Paralysis. 

When  wc  speak  of  paralysis,  we  mean  a  loss  of  muscular  con- 
tractility, and,  as  a  consequence,  of  the  power  of  motion,  although 
there  is  the  impulse  of  the  will  to  move  the  affected  part.  It  is 
true,  there  is  also  a  paralysis  of  sensation,  a  complete  anass- 
thesia,  which  may  be  conjoined  with  the  paralysis  of  motion ; 
but  the  latter  often  happens  alone,  and  is  the  morbid  state  alluded 
to  when  we  use  the  w^ord  paralysis  without  qualifying  it.  A 
slight,  incomplete  paralysis  is  called  "paresis,"  and  this  term 
is  especially  employed  when  the  loss  of  power  exists  without  de- 
monstrable organic  change. 

Paralysis  is  nearly  always  of  nervous  origin.  It  may  be  gen- 
eral, or  it  may  be  partial.     It  may  affect  the  majority  of  the  mus- 

*  Gowers,  Diagnosis  of  Diseases  of  the  Spinal  Cord,  London,  1880;  and 
Diseases  of  the  Nervous  System,  1888. 


DISEASES   OF   THE   BRAIN    AND   SPINAL   CORD.  91 

cles  of  the  frame,  or  be  limited  to  one  muscle.  It  may  be  strictly 
confined  to  one  side,  or  exist  solely  in  the  lower  half  of  the  body. 
It  may  come  on  rapidly,  or  appear  slowly.  But  under  any  cir- 
cumstances it  is  not  a  disease,  but  a  symptom.  We  must,  in  in- 
dividual cases,  therefore,  aim  at  determining,  so  far  as  possible,  its 
cause,  before  we  attempt  to  remedy  the  palsy.  The  causes  Avhich 
give  rise  to  paralysis  may  be  thus  summed  up  : 

Paralysis  due  to  a  lesion  or  any  morbid  condition  of  the  nervous 
centres. — Hemorrhage  into  or  softening  of  the  central  nervous 
textures,  or  any  other  process  which  materially  alters  them  or 
interrupts  the  main  conducting  paths,  occasions  loss  of  power  in 
the  part  over  which  their  influence  in  health  extends.  The  com- 
plete paralysis  attending  most  of  the  diseases  of  the  brain  and  of 
the  spinal  cord  belongs,  therefore,  in  this  category. 

But  besides  these  palsies  of  organic  origin  there  are  functional 
palsies,  dependent  upon  what,  so  far  as  we  are  aware,  is  simply 
a  functional  derangement  of  the  great  centres  of  innervation. 
Hysterical  paralysis,  and  that  occurring  after  overwork  or  ex- 
cesses, and  from  nervous  exhaustion,  are  examples. 

Paralysis  due  to  a  lesion  in  the  course  of  a  nerve. — The  nervous 
force  may  be  properly  generated,  but  the  nerve-fibres  may  be  in- 
capable of  conducting  it.  For  instance,  if  a  nerve  be  wounded  or 
compressed,  paralysis  of  the  muscles  which  it  supplies  takes  place. 
Palsy  from  this  cause  is  local,  and  is  apt  to  show  marked  nutritive 
changes  in  the  affected  part,  such  as  glossy  fingers  and  swollen 
joints,  and  to  be  associated  with  pain. 

Paralysis  due  to  an  affection  of  the  nerves  at  their  extremities. — 
An  illustration  of  such  a  disorder  is  the  palsy  resulting  from 
exposure  to  cold.  Peripheral  palsies  lead  quickly  to  atrophy  of 
the  muscles.  They  are,  from  their  very  nature,  local,  and  com- 
monly remain  so.  But  many  peripheral  nerves  may  become  im- 
plicated, and  extensive  palsies  result,  as  seen  in  multiple  neuritis. 

Paralysis  due  to  reflex  action. — Here  the  paralysis  is  produced 
through  the  reflex  centres,  which  reflect  the  irritation  communicated 
to  them  to  parts  healthy  in  themselves.  At  all  events,  cases  are 
from  time  to  time  met  with  which  admit  of  no  other  explanation. 
How  else  can  excitation  of  the  dental  nerves  in  teething  children, 
or  disorders  of  the  intestines  both  in  adults  and  in  children,  or 
disease  of  the  bladder,  urethra,  prepuce,  uterus,  lungs,  or  pleura, 


92  MEDICAL    DIAGNOSIS. 

or  irritation  of  the  nerves  of  the  skin,  occasion  paralysis?  or  how 
else  can  a  wound  of  a  nerve  on  one  side  of  the  body  load  to  palsy 
on  the  other  ?  The  most  common  cause  of  the  affection  is  periph- 
eral irritation.  But  the  question  as  to  the  state  of  the  nerve- 
centres  in  reflex  paralysis,  and  how  they  become  implicated,  is  still 
unsettled.  It  is  held  by  some,  by  Leydcn  in  particular,  that  a 
true  neuritis,  or  at  least  a  high  degree  of  congestion,  travels  along 
the  nerves  until  it  reaches  the  cord. 

Paralysis  brought  on  by  reflex  action  is  rarely  of  long  duration. 
It  develops  gradually,  is  increased  or  diminished  as  the  causes 
"which  produce  it  increase  or  diminish,  and,  as  a  rule,  soon  dis- 
appears after  the  source  of  disturbance  is  removed.  It  may  affect 
almost  any  part  of  the  body,  and  assumes  often  the  paraplegic 
form. 

Paralysis  due  to  serious  interference  vitli  the  circulation. — This 
kind  of  palsy  is  observed  if  the  principal  artery  of  a  part  be  ob- 
literated. But  it  is  not  often  encountered,  and,  when  met  with,  is 
not  unusually  found  to  be  connected  with  gangrene  of  the  para- 
lyzed part.  It  is  sometimes  noticed  as  a  transient  phenomenon 
after  the  ligation  of  a  largo  artery.  If  the  vascular  supply  of 
the  brain  be  interfered  with  by  the  occlusion  of  a  vessel,  wlietlier 
by  embolism  or  by  thrombosis,  the  hemiplegia  that  results  is  more . 
permanent  and  very  marked.  Among  the  circulatory  disturbances 
that  may  lead  to  palsies  we  must  not  forget  to  look  for  the  altered 
blood-tension  produced  by  disease  of  the  heart,  and  the  degenera- 
tion of  the  vessels  caused  by  Bright's  disease. 

Paralysis  due  to  a  morbid  state  of  the  muscles. — Any  process 
which  materially  impairs  the  normal  structure  of  muscular  tissue 
will  entail  loss  of  muscular  power ;  but,  in  point  of  fact,  the  dis- 
eases which  commonly  occasion  this  form  of  paralysis — if  it  be 
correct  to  call  that  paralysis  in  which  the  nervous  system  is  not  to 
appearance  primarily  or  particularly  concerned — are  certain  forms 
of  rheumatic  palsy  and  of  muscular  atrophy. 

Paralysis  due  to  the  presence  of  jjoisons  in  the  system. — The 
toxical  effects  of  lead,  of  arsenic,  of  mercury,  of  alcohol,  and  of 
sulphuret  of  carbon,  may  exhibit  themselves  by  producing  palsy. 
Malarial  poisons,  and  poisons  formed  in  the  system,  such  as  that 
of  rheumatism  or  of  srout,  mav  act  in  the  same  wav.  The  former 
occasion  that  singular  "  intermittent  paralysis"  which  may  come 


DISEASES    OF   THE    BRAIN    AND    SPINAL    COED.  93 

on  either  as  one  of  the  plienomena  of  a  fit  of  ague,  or  as  an 
apparently  independent  complaint,  which  assumes  either  the  quo- 
tidian or  the  tertian  type,  and  in  which  both  sensation  and  motion 
may  be  affected.  How  any  of  these  poisons  operate,  whether  by 
interfering  with  the  nutrition  of  the  nervous  centres  and  weaken- 
ing their  generating  force,  or  by  enfeebling  the  conducting  power 
of  the  nerves,  is  unknown.  The  palsies  coming  under  this  head, 
being  for  the  most  part  functional,  are  not  ordinarily  intractable. 
Those  due  to  malaria  yield  speedily  to  decided  doses  of  quinia. 
Similar  to  the  palsies  of  poisons  and  certain  cachexias  are  the 
palsies  produced  by  changes  in  the  blood  after  acute  diseases.  Yet 
actual  structural  changes  have  been  found  in  these  paralyses  of 
blood  origin. 

In  the  parts  affected  with  paralysis  the  nutrition  and  secretion 
are  disturbed  and  the  circulation  is  sluggish.  They  are  frequently 
swollen  and  oedematous,  the  pulse  is  weaker  than  in  the  sound 
members,  and  the  sensation  is  impaired.  The  nails  grow  slowdy,* 
so  do  the  hairs ;  the  perspiration  is  defective ;  the  skin  feels  cold, 
is  prone  to  break  from  the  effect  of  pressure,  or  even  indepen- 
dently of  it,  and  the  ulcers,  if  they  heal  at  all,  heal  but  tardily. 
The  condition  of  the  muscles  is  various.  In  some  cases  they  are 
completely  relaxed,  in  others  rigid  ;  at  times  they  become  agitated 
with  convulsive  movements.  These  phenomena  are  most  evident 
in  palsies  of  organic  origin,  especially  in  those  dependent  upon 
a  brain-lesion,  and  in  those  due  to  disease  of  the  spinal  cord  in 
which  anaesthesia  is  jjresent.  Where  hyperesthesia  occurs,  the 
increased  sensibility  is  attended  with  a  larger  supply  of  blood  and 
a  higher  local  temperature. 

At  times  there  are  involuntary  movements  in  the  paralyzed 
parts.  Thus,  in  cases  of  hemiplegia  there  may  be  automatic  move- 
ments in  the  palsied  arm  when  the  patient  sneezes,  or  some  action 
in  the  muscles  of  the  face  to  cause  expressions  in  connection  with 
those  of  the  sound  side.  Again,  muscles  which  are  commonly 
associated  in  bilateral  action  no  longer  exhibit  this,  or  an  attempt 
only  at  action  is  ^perceptible ;    or  certain    muscles  which  are  in 


*  Weir  Mitchell  (Injuries  of  Nerves,  and  their  Consequences)  states  that  the 
nail-growth  is  abolished  in  recent  cerebral  palsies,  and  that  in  functional  palsies 
it  persists. 


94  MEDICAL    DIAGNOSIS. 

the  habit  of  acting  togotiicr  to  cause  a  jmrticuhir  result  do  so  no 
longer.  A  common  illustration  is  rotation  of  the  head  and  neck 
to  the  same  side  as  the  one  to  which  the  eyes  are  directed,  and 
thus  lateral  or  ''  conjugate"  deviation  of  the  eves  takes  place,  as 
a  rule,  away  from  the  seat  of  lesion  and  toward  the  paralyzed 
side.  This  symptom  is  often  transitory,  but  is  generally  found 
in  sudden  marked  hemiplegia. 

Having  examined  some  of  the  general  traits  and  the  causes 
of  paralysis,  let  us  investigate  its  chief  varieties  with  reference 
to  their  significance  and  diagnosis.  In  so  doing,  it  will  be  con- 
venient to  be  guided  by  the  marked  coarse  features  rather  than 
by  the  presumed  origin. 

But  before  insjjecting  these  we  shall  briefly  inquire  into  the 
mode  in  ichich  palsies  are  investigated  at  the  bedside.  We  ascertain, 
of  course,  the  size,  appearance,  and  feel  of  the  stricken  part ;  take 
notice  of  its  growth,  and  of  the  nutritive  changes,  such  as  altera- 
tions in  look  and  action  of  the  skin,  the  presence  on  it  of  erup- 
tions and  of  breaks,  the  state  of  the  cutaneous  circulation,  of  the 
nails,  the  hair,  and  the  joints.  Then  we  test  the  sensibility  to  con- 
tact, to  tickling,  to  pinching,  to  heat  and  cold  ;  measure  the  tactile 
sense  by  the  ^esthesiometer ;  and  carefully  note  any  reflex  move- 
ments that  may  be  produced  in  the  apparently  lifeless  limb,  con- 
trasting them  with  those  of  the  sound  limb.  AVe  next,  where 
minuteness  of  investigation  is  desirable,  ascertain  the  surface 
temperature ;  and  pass  on  to  a  thorough  study  of  the  condition 
of  the  muscles  and  of  muscular  motion. 

Now,  in  examining  the  muscles  we  do  not  find  them  more 
W' asted  than  their  disuse  will  account  for, — certainly  not  in  palsies 
of  cerebral  origin.  Moreover,  we  generally  observe  them  to  be 
flaccid,  rigidity,  especially  early  rigidity,  being  rare  ;  but  a  stiffen- 
ing associated  with  pain  in  attempts  to  straighten  the  ct)ntracted 
part  is  not  so  rare  Avhere  the  palsies  have  been  of  longer  standing, 
and  has  had,  as  we  shall  see  presently,  a  special  meaning  attached 
to  it.  Then,  irrespective  of  the  condition  of  flaccidity  or  stifft-n- 
ing,  we  must  look  into  the  degree  of  abolition  of  muscular  mo- 
tion, carefully  contrasting  it,  when  one-sided,  as  indeed  we  must 
all  the  phenomena  under  investigation,  with  the  movements  of  the 
other  side.  Is  the  motion  completely  abolished,  or  only  impaired? 
what  muscles  particularly  are  aifected?  are  concerted  movements 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD. 


95 


possible?  and  how  is  the  gait,  if  we  are  testing  the  muscles  of 
the  legs,  during  these  movements  ?  Moreover,  what  amount  of 
muscular  effort  is  required  to  overcome  special  resistance  ?  how  is 
the  balancing  power?  and  how  are  delicate  and  combined  move- 
ments executed  when  the  eyesight  is  withdrawn?  When  the 
power  in  the  arms  is  only  impaired,  not  lost,  we  asc-ertain  the 
degree  roughly  by  the  strength  of  the  grasp.  But  we  can  do 
so  accurately  by  a  dynamometer.  Of  these,  the  best  is  that  of 
Mathieu  (Fig.  9),  consisting  of  a  steel  ring,  slightly  elastic,  which 

Fig.  9. 


is  pressed  firmly  in  the  hand  and  records  the  pressure.  The  de- 
gree of  swaying  of  the  patient,  or  "  station,"  as  AYeir  Mitchell* 
calls  it,  may  also  be  accurately  measured. 

But  the  most  valuable  agent  to  judge  of  the  state  of  the  mus- 
cles is  eledriciti/,  especially  the  forms  of  it  known  as  the  induced 
current,  or  "  faradization,"  and  the  constant  current,  or  "  galvan- 
ization," and  the  action  of  each  must  be  separately  studied.  The 
parts  to  be  examined  should  occupy  similar  positions,  and  the 
muscles  of  the  sides  to  be  compared  should  be  in  equal  condition 
of  tension.  We  must  begin  with  a  weak  current,  and  the  wet 
electrodes  are  placed,  one  on  the  muscle  itself,  the  other  on  some 
other  part  of  the  muscle  or  some  indifferent  point.  This  is  the 
direct  excitation  of  the  muscle.  Or  the  muscular  action  may  be 
evoked  by  stimulating  the  motor  nerve  supplying  the  muscle  to 
be  tested.  This  is  indirect  excitation  ;  and  in  healthy  muscles  the 
same  strength  of  current  will  produce  the  same  amount  of  con- 
traction whether  muscle  or  motor  nerve  be  stimulated.  It  is 
also  important  to  break  the  current  by  slow  interruptions,  and, 
especially   in    employing   the   galvanic  current,  to  compare  the 


*  Amer.  Journ.  31  ed.  Sci.,  April,  1887. 


96  MEDICAL    DIAGNOSIS. 

positive  (anodal)  and  the  negative  (eathodal)  opening  and  closing 
contractions  of  the  diseased  with  those  of  the  sound  side.  In 
l)oth  currents,  too,  we  shouUl  ascertain  ^liat  the  (juantitative 
changes  are, — whether  the  muscles  react  under  a  feebler  current 
than  is  usual,  or  require  one  of  great  strength  to  move  them. 

Diminished  or  lost  electro-muscular  contractility  is  a  most  valua- 
ble sign  in  destructive  diseases  of  the  cord.  Indeed,  speaking  in 
general  terms,  we  may  say  that  it  belongs  to  sjnnal  palsies,  A\hile 
the  electro-muscular  contractility  is  intact  in  cerebral  palsies. 
But  the  statement  must  not  be  accepted  absolutely.  It  is  only 
true  of  spinal  palsies  when  the  muscles  are  separated  entirely 
from  the  influence  of  the  cord  :  those  supplied  by  nerves  having 
their  origin  in  healthy  spinal  texture  preserve  their  normal  irrita- 
bility. In  truth,  if  the  uninjured  part  of  the  cord  has  become 
irritated,  or  more  vascular,  the  muscles  having  a  nervous  con- 
nection with  it  may  show  increased  susceptibility  to  the  electric 
current,  and  more  energetic  contraction.  Again,  diminished  elec- 
tro-muscular contractility  is  not  always  due  to  a  spinal  lesion. 
We  find  it  when  the  nerve  itself  is  injured,  and  it  then  comes  on 
very  quickly ;  when  there  is  a  mere  local  change  in  the  muscular 
texture  of  the  helpless  part ;  and  as  the  result  of  certain  poisons, 
as  of  opium,  lead,  rheumatism,  or  other  blood-poisons,  which 
lower  the  power  of  nerve,  of  muscle,  or  of  nerve-centre.  We 
find  it  also  when  there  has  been  long  disuse  of  a  limb,  as  in  old 
cases  of  hysterical  palsy,  and  even  of  cerebral  palsy.  But  under 
these  circumstances  it  is  temporary,  not  permanent ;  for  using 
the  battery  for  a  few  days  makes  the  greatest  change  in  the 
electro-muscular  contractility.  Lastly,  there  are  certain  cases  of 
spinal  paraplegia,  farther  on  more  particularly  to  be  studied,  and 
of  disordered  motility  with  lesions  in  the  posterior  columns,  as 
in  locomotor  ataxia,  and  slight  peripheral  palsies,  in  Mhich  the 
electro-muscular  contractility  is  not  markedly  damaged. 

As  already  stated,  the  electro-muscular  contractility  is  normal 
in  all  the  forms  of  palsy  due  to  brain  disease.  The  palsied  limb 
may  have,  indeed,  its  muscles  more  powerfully  convulsed  by  a 
current  of  the  same  intensity  than  those  of  the  sound  side  are,  and 
then  we  may  infer,  as  Todd  *  and  Althaus  f  have  shown,  that  the 

*  Clinical  Lectures  on  the  Nervous  System.  f  Medical  Electricity. 


DISEASES    or    THE    BRAIN    AND    SPINAL    CORD,  97 

paralysis  is  due  to  brain  disease  of  an  irritative  character.  In 
recent  hemiplegias,  whatever  their  origin,  increase  of  electric  ex- 
citability is  not  uncommon.  The  response  of  muscle  to  faradaic 
stimulation  is  called  faradaic  excitability ;  and  the  remarks  made 
are  based  on  the  effects  obtained  by  faradization.  With  reference 
to  the  galvanic  or  continuous  current,  or  galvanic  excitability,  we 
find  that  a  galvanic  current  may  give  the  same  or  it  may  give 
different  results.  In  a  healthy  state  of  the  muscles  the  galvanic 
current  gives  the  same  results  as  faradization,  whether  muscle 
itself  or  its  motor  ners^e  be  acted  on.  But  in  diseased  conditions 
this  is  not  the  case ;  galvanism  may  show  the  same  or  it  may 
show  different  reactions.  As  regards  the  galvanic  excitability,  it 
disappears  in  this  progression  :  first  the  cathodal  closing  tetanus 
(KaS  Te),  then  the  anodal  closing  contraction  (An  SZ),  then  the 
anodal  opening  contraction  (An  OZ),  and  lastly  the  cathodal 
closing  contraction  (Ka  SZ)  can  be  excited  only  with  the  strongest 
current,  if  at  all.  This  kind  of  decline  shows  itself  markedly 
where  the  muscles  waste,  as  in  progressive  muscular  atrophy, 
and  some  spinal  palsies  with  wasting  muscles.  The  muscles  of  a 
palsied  part  may  respond  actively  to  galvanization  and  not  at  all 
to  faradization.  We  observe  this  when  the  muscular  tissue  has 
begun  to  atrophy  and  to  degenerate  in  consequence  usually  of 
an  extensive  disease  of  the  cord  and  in  traumatic  nerve  lesions. 
While  the  faradaic  excitability  declines  or  is  lost,  the  galvanic 
excitability  not  only  remains,  but  may  be  even  exaggerated ;  and 
in  this  "  reaction  of  degeneration"  there  are  also  complete  changes 
in  the  normal  laws  of  electric  muscular  contraction  :  the  anodal 
closing  contraction  equals  or  even  exceeds  the  cathodal  closing 
contraction,  the  cathodal  opening  contraction  declines  in  the 
same  manner.  Again,  we  may  find  dissimilarities  by  interrupt- 
ing the  galvanic  current,  and  these  may  vary  wdiether  the  cur- 
rent be  rapidly  or  slowly  broken.  Thus,  Russell  Reynolds  *  has 
shown  us  that  in  certain  instances  of  facial  palsy  from  exposure  to 
cold,  or  in  paralysis  of  the  limbs  from  the  same  cause,  or  in  lead 
palsy,  the  muscles  act  as  little  under  the  rapidly-interrupted  gal- 
vanic current  as  under  faradization ;  but  if  the  galvanic  current 
be  slowly  interrupted,  they  exhibit  a  greater  amount  of  irritability 

*  Clinical  Uses  of  Electricity,  London,  1873. 

7 


98  MEDICAL    DIAG^'OSIS. 

than  do  the  healthy  niusek^s.  In  these  eases  it  is  found  that 
the  museles  are  priniaril}'  atteeted,  and  the  applieation  of  slowly- 
interrupted  galvanism  is  ra})idly  of  mueh  service.  It  is,  indeed, 
well  in  all  eases  of  jialsy,  Mhatever  be  the  form  of  battery  em- 
ployed, to  note  the  difl'erenees  in  the  contraction  of  the  museles 
produced  by  sIom-  or  rapid  interruptions.  The  "  reaction  of  de- 
generation" may  be  so  modified  as  to  be  abnormally  slow  to  both 
kinds  of  electrical  nerve  excitation  and  to  iaradaic  muscle  excita- 
tion.* Static  or  Franklinic  electricity  may  also  be  employed  for 
purposes  of  diagnosis.  We  meet  with  instances  where  nniscles 
contract  under  its  use  which  do  not  respond  to  either  the  faradaic 
or  the  galvanic  current. 

As  already  stated,  a  muscle  may  be  indirectly  acted  on ;  one 
moistened  electrode  is  placed  over  the  motor  nerve  which  controls 
the  muscle,  the  other  over  its  body.  In  inflammation  of  the  nerve 
both  galvanic  and  faradaic  irritability  of  the  muscle  is  increased  ; 
in  destructive  injuries  it  lessens  and  disappears.  It  is  always  well 
to  note  the  indirect  as  well  as  the  direct  muscle  excitation.  But 
it  has  not,  for  purposes  of  diagnosis,  proved  itself  as  generally  valu- 
able. We  should  endeavor  to  place  the  one  or  other  of  the  sponges 
exactly  over  the  seat  of  chief  nerve-supply  in  the  muscle  ;  and  the 
ascertainment  of  the  nerve  point  or  points  that  correspond  Avith 
the  entrance  of  the  motor  nerves  into  the  muscles  has  been  made 
a  matter  of  much  study.  Experience,  indeed,  proves  that  from 
these  motor  points,  determined  with  infinite  care  and  labor  by 
Ziemssen,t  the  readiest  control  of  the  muscles  is  obtained. 

When  the  inuscles  react  under  electricity  the  contraction  is  felt, 
and  the  "  electro-muscular  sensibility"  is  more  decided  the  stronger 
the  contraction.  Hence  we  almost  always  find  increased  electro- 
muscular  contractility  with  increased  electro-muscular  sensibility. 
But  the  latter  may  exist  alone,  as  we  mostly  observe  in  myalgias. 
On  the  other  hand,  the  relationship  between  diminished  contrac- 
tility and  sensibility  may  be  changed,  as  we  find,  for  instance, 
in  the  striking  want  of  sensibility  to  the  current  in  hysterical 
paralysis.      The  electric  reactions  of  the  skin,  well  tested  by  a 


*  Erb,  Brain,  April,  1883. 

f  Die  Electricitat  in  dcr  Medicin  ;  also  Tibbits's  Handbook  of  Electricity, 
and  Bartholow's  Medical  Electricity,  Philadelphia,  1887. 


DISEASES    OP   THE    BRAIN    AND    SPINAL    CORD.  99 

metallic  brush,  as  a  rule  go  liancl  iu  liand  with  the  reactions 
of  the  muscles,  increase  in  sensitiveness  with  them,  deci-ease  with 
them. 

Such  are  the  chief  facts  with  reference  to  the  diagnostic  appli- 
cations of  electricity  in  paralysis.  There  is  yet  another  mode  of 
investigation  which  we  constantly  bring  into  use,  one  also  in 
which  the  action  of  the  muscles  particularly  gives  us  valuable  in- 
formation concerning  the  state  of  the  nervous  system, — the  testing 
of  the  reflex  excitability.  But  we  have  already  examined  into  the 
derangement  of  the  reflex  system,  and  shall  only  here  add  a  few 
general  clinical  facts.  We  find  the  reflex  excitability  diminished 
in  disease  of  the  gray  substance  of  the  cord,  in  disease  of  the  sen- 
sory root-fibres,  which  thus  become  incapable  of  conducting  the 
impression,  and  in  disease  of  the  motor  fibres,  which  fail  to  impart 
the  motor  impulse.  In  the  latter  case  there  is  coexisting  paralysis 
of  motion ;  in  the  second,  auEesthesia.  Increase  of  reflex  excita- 
bility, producing  twitching  or  even  violent  irregular  movement  on 
very  slight  stimulation,  is  found  in  all  irritative  lesions  which 
have  increased  the  excitability  of  the  gray  substance  of  the  cord,  as 
when  this  is  disturbed  by  inflammation,  or  compressed  by  a  tumor, 
or  heightened  by  certain  drugs,  such  as  strychnine.  Increase  of 
reflex  excitability  is  also  found  in  parts  below  a  lesion,  when  this 
is  so  complete  that  it  cuts  off  the  healthy  gray  substance  of  the 
cord  from  the  controlling  action  of  the  brain,  as  in  large  tumors 
and  spinal  apoplexies. 

As  regards  the  action  of  the  brain,  there  are  instances  in  which, 
if  all  power  of  appreciating  impressions  be  lost,  as  in  overwhelm- 
ing cerebral  apoplexies,  reflex  action  may  be  everywhere  susj^ended. 
On  the  other  hand,  we  find  signs  of  reflex  action  manifesting 
themselves  by  irritation  transferred  from  diseased  to  healthy  parts 
of  the  brain,  producing  spasms  or  palsy  phenomena,  alluded  to  in 
the  sketch  of  the  seat  of  cerebral  lesions.  Nor  must  we  from  a 
clinical  point  of  view  omit  to  mention  the  reflex  actions  excited 
in  other  parts  of  the  body,  as  from  diseases  of  bones  and  joints, 
or  the  muscular  contractions  in  the  legs  during  catheterization  or 
in  colics.  Here  the  seat  of  the  perverted  reflex  action  is  entirely 
in  the  reflex  areas  of  the  cord. 

All  these  remarks  tell  us  how  to  examine  paralysis.  Having 
now  studied  the  modes  in  which  this  is  investigated,  I  shall  merely 


100  MEDICAL    DIAGNOSIS. 

recall  that  to  find  out  the  cause  of  the  difficulty  we  have  to  take 
iuto  aceouut  the  history  of  the  case,  aud  the  attendino;  symptoms, 
nervous  and  otherwise ;  and  in  elieitinu'  tliese  we  sliould  never 
forget  to  bring  out  prominently  those  shown  us  l)y  the  ophthal- 
moscope and  by  examinatit)n  of  the  urine  and  the  heart. 
Let  us  return  to  the  clinical  study  of  palsies. 

HEMIPLEGIA. 

We  shall  first  consider  that  form  whicli  almost  always  results 
from  brain  disease, — hemiplegia,  or  one-sided  palsy.  This  state 
of  things  may  aifect  all  the  voluntary  muscles  on  one  side  of  the 
body ;  but  it  generally  exists  only  in  those  of  the  limbs  and  face  ; 
the  eye,  neck,  and  trunk  muscles  escape.  Neither  the  legs  nor  the 
arms  can  move,  and  the  muscles  of  the  face  on  the  side  correspond- 
ing to  the  paralyzed  limbs  are  motionless.  The  cheek  hangs;  the 
mouth  is  drawn  toward  the  healthy  side,  because  the  muscles  on 
the  other  are  powerless  to  resist ;  the  tongue,  when  protruded,  is 
ordinarily  slowly  pushed  out  toward  the  palsied  side  ;  the  articu- 
lation is  imperfect. 

But  the  rule  with  respect  to  the  face  being  paralyzed  on  the 
same  side  as  the  rest  of  the  body  has  its  exceptions.  Indeed, 
when  we  reflect  that  the  nerves  which  sup])ly  the  fiicial  nniscles 
are  given  off  above  the  point  of  decussation  of  the  nervous  fibres 
in  the  cord,  it  seems  perplexing  that  it  should  be  a  rule  at  all. 
The  solution  of  the  question  lies  in  the  crossing  of  the  facial 
nerves.  Should,  then,  the  lesion  be  seated  in  the  brain  above  this 
crossing,  both  face  and  body  are  paralyzed  on  the  side  opposite  to 
the  diseased  spot.  Sliould,  however,  the  lesion  involve  the  facial 
nerve-fibres  at  a  point  below  or  after  the  decussation,  there  will 
be  paralysis  of  the  face  on  one  side,  and  of  the  limbs  on  the  other, 
the  facial  palsy  being  direct,  and  that  of  the  body  being  crossed. 

Now,  according  to  Gubler,*  this  cross  parali/sis  is  always  in- 
dicative of  a  lesion  of  the  pons  Varolii,  close  to  which  the  facial 
nerves  originate,  and  throuo-h  which  the  nerve-fibres  for  the  limbs 
]iass  before  they  decussate  lower  down.  But  we  must  remember 
that  there  are  rare  cases  of  "alternating  hemiplegia,"  due  to 

*  De  riiemiplegie  alterne  envisagee  comme  signe  cle  lesion  de  la  protuLe- 
rance  annulairc,  Gaz.  Hebdoni.,  1856,  1859.  . 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  101 

a  combination  of  lesions,  one  affecting  a  cerebral  lolje  on  one 
side  and  the  facial  nerve  on  the  other.  Even  when  the  lesion 
is  unilateral,  we  may  meet  with  exceptional  cases ;  and,  as  Bas- 
tian  *  points  out,  the  lesion  may  be  situated  in  the  pons,  the  palsy 
of  face  and  limbs  liot  being  alternate,  provided  the  disease  occur 
in  the  upper  or  anterior  part  of  one  lateral  half,  implicating  the 
fibres  of  the  facial  above  their  sites  of  decussation.  With  refer- 
ence to  the  other  cerebral  nerves,  should  we  find  any  of  them 
paralyzed  on  one  side  and  the  body  on  the  other,  we  shall  gener- 
ally be  correct  in  assuming  that  the  palsy  is  not  due  to  disease  on 
both  sides  of  the  brain,  but  is  rather  a  disturbance  of  the  affected 
nerve  near  its  origin  or  in  its  course,  and  on  the  side  on  which 
the  brain  is  injured,  while  the  paralysis  of  the  limbs  is  on  the 
opposite  side.  Anatomical  researches  which  have  traced  con- 
necting nuclei  on  the  floor  of  the  fourth  ventricle  and  elsewhere 
explain  these  alternating  palsies. 

Hemiplegia,  as  already  stated,  results,  in  the  vast  majority  of 
instances,  from  cerebral  disease.  Hence  we  find  it  commonly 
associated  with  disordered  mental  powers,  and  other  signs  of  a 
brain-lesion.  We  observe  that  the  reflex  acts  are  normal  or  exag;- 
gerated  ;  that  the  rectum  and  the  bladder  perform  their  functions. 
Hemiplegia  caused  by  an  affection  of  one-half  of  the  spinal  cord, 
near  its  commencement,  is  not  combined  with  a  decay  of  the  mental 
faculties,  but  the  muscles  of  the  chest  and  abdomen  are  involved 
in  the  paralysis,  which  they  are  not  in  cerebral  hemiplegia,  unless 
the  lesion  be  very  extensive.  Then  in  spinal  hemiplegia  there  is 
coexisting  ansesthesia,  as  Brown-Sequard  has  shown,  on  the  side 
opposite  to  the  lesion  and  the  muscular  palsy,  and  the  temperature 
sense  is  impaired,  as  is  the  sensibility  to  pain ;  the  palsied  limb 
gives  evidences  of  vaso-motor  paralysis,  has  a  higher  temperature, 
and  is  hypersesthetic ;  reflex  action  is  increased  on  the  side  of  the 
lesion,  the  muscular  sense  is  impaired,  and  the  umbilicus  is  with 
every  act  of  inspiration  drawn  toward  the  sound  side.  We  pos- 
sess a  further  test  in  electricity  :  unlike  what  happens  in  cerebral 
paralysis,  the  electro-muscular  contractility  is  greatly  lessened  or 
is  lost ;  but  Gowers  has  shown  that  the  electrical  irritability  of 
the  nerves  on  the  palsied  side  is  greater  to  both  currents.     Spinal 

*  Paralvsis  from  Brain  Disease,  1875. 


102  MEDICAL    DIAGNOSIS. 

hemiplegia,  or  '^  hemijiaraplegia,"  as  it  is  more  often  called  if 
the  lesion  be  lo\\'  down,  occurs  from  injuries,  tumors,  syphilitic 
disease  of  the  cord,  and  localized  sclerosis.*  According  to  Rom- 
berg, s])in;il  heini})lcgia  is  more  persistent  in  the  leg  than  it  is  in 
the  arm. 

But  supposing  that  we  have  settled  the  hemiplegia  to  be  cere- 
bral, the  points  next  to  be  investigated  are,  where  is  the  lesion 
situated  ?  and  what  is  its  nature  ?  Now,  the  former  question, 
concerning  ilie  anatomical  diagnosis,  may  be  answered  in  a  general 
way  by  stating  that  the  disease  is  on  the  side  opposite  to  the  palsy, 
if  the  lesion,  as  it  almost  always  is,  be  seated  above  the  point 
of  decussation  of  the  pyramidal  columns  of  the  medulla ;  for  a 
lesion  below  the  decussation  gives  rise  to  palsy  on  the  same  side, 
and  a  lesion  on  a  level  with  the  decussation,  to  double-sided  palsy. 
Furthermore,  we  may  reasonably  conclude  that  tlie  morbid  process 
has  affected  the  corpus  striatum,  if  motion  be  seriously  impaired, 
while  sensation  is  unaffected  ;  or  has  attacked  the  ojjfic  thalamus, 
if  there  lie  not  very  marked  motor  palsy,  early  tonic  and  ck)nic 
spasms  in  the  palsied  limbs,  especially  in  the  hand,  or  about  the 
face  and  neck,  and  decided  difference  in  temperature  between  the 
limbs  on  the  paralyzed  and  on  the  sound  side,!  some  impairment 
of  sensation  and  absence  of  vaso-motor  symptoms ;  yet,  in  point 
of  fact,  so  intimate  is  the  union  between  the  corpus  and  the  thala- 
mus that  one  is  hardly  ever  much  disorganized  without  the  other 
being  drawn  into  the  disease. 

The  nearer  the  lesion  to  the  surface,  the  more  marked  are  the 
mental  phenomena,  the  greater  is  the  tendency  to  spasms  in  the 
limbs,  but  the  more  incomplete  is  the  palsy  ;  and  the  farther  the 
disease  extends  toward  the  corpus  striatum  and  the  internal  cap- 
sule, the  more  thorough  does  the  paralysis  of  motion  become. 
We  may  further  distinguish  the  palsy  which  ensues  from  that 
caused  by  an  affection  lower  down,  as  of  the  pons  VaroUi,  by 
observing  that,  besides  the  peculiar  crossed  paralysis  of  the  face 
and  limbs,  we  find  extreme  coldness  of  that  side  of  the  I)()dy  which 
is  to  become  paralyzed  after  a  time  ;  also  giddiness  and  a  tendency 

*  Cases  l)y  Charcot  and  Gombault,  and  by  Troisier,  Archives  de  Physio- 
logic, 1873;  by  Eiegel,  Berlin.  Klin.  Wochenschrift,  1873,  and  by  F.  Eemal<, 
ib.,  1877. 

f  Bastian,  Paralj'sis  from  Brain  Di.<ease,  1875. 


DISEASES    OF    THE    BRAIN    AND    SPINAL   CORD.  103 

to  vomit ;  jironeness  to  cry  or  laugh  without  sufficient  cause  ;  jerk- 
ings  of  the  muscles  of  the  face  on  the  side  opposite  to  the  injury ; 
sensations  of  ticklings  in  the  face ;  and  one-sided  facial  anaesthesia, 
with  a  loss  of  sense  of  taste  on  the  corresponding  side,  though  witli 
unimpaired  motion  of  the  tongue.  Should  we  encounter  paralysis 
of  sensibility  and  motion  on  one  side  of  the  body,  and  both  sides 
of  the  face  be  palsied  as  to  motion  and  sensation,  should  the  recti 
muscles  of  the  eye  be  paralyzed,  and  taste  be  lost  over  the  anterior 
part  of  the  tongue,  we  may  infer  that  the  injury  is  seated  rather 
above  the  lower  portions  of  the  pons,  and  affects  the  spot  where 
the  facial  nerve  and  part  of  the  trigeminal  cross.*  Hyperpyrexia 
is  not  uncommon  after  the  onset  of  an  acute  lesion  of  the  pons, 
and  in  acute  lesions  convulsions  f  also  are  common,  as  is  marked 
contraction  of  the  pupils. 

In  lesions  involving  the  central  parts  of  the  pons,  paralysis, 
mostly  unequal,  of  both  sides  of  the  body,  with  impaired  sensa- 
tion, irregular  facial  palsy,  difficulty  in  deglutition  and  articula- 
tion, is  the  rule.  Lesions  of  the  lower  and  inner  part  of  the  cms 
cerebri  Hermann  Weber  has  taught  us  to  recognize  by  an  alternate 
jmralysis,  in  which  the  third  nerve  is  palsied  on  the  side  of  the  brain 
affected,  showing  us  want  of  action  of  the  muscles  of  the  eyeball, 
except  the  external  rectus  and  superior  oblique,  with  a  dilated 
pupil,  a  tongue  deviating  to  the  paralyzed  side,  some  difficulty  in 
articulation,  the  body-palsy  marked  in  the  arm  and  leg,  and  co- 
existing with  local  temperature  higher  by  several  degrees,  vaso- 
motor disturbance,  and  very  defective  sensation. 

Besides  these  well-attested  facts,  the  brilliant  researches  of  the 
day  on  the  localization  of  cerebral  functions  have  already  solved, 
and  are  solving,  many  problems  as  important  to  the  physician 
as  to  the  physiologist.  Let  us  look  at  some  of  the  additions  to 
pathological  knowledge  which  appear  the  most  certain. 

We  shall  first  glance  at  lesions  of  the  motor  zone,  or  rather  of 
the  convolutions  functionally  related  to  the  corpus  striatum.  They 
include  the  basis  of  the  three  frontal  convolutions  bounding  the 
fissure  of  Rolando,  and  are  supplied  by  branches  of  the  middle 
cerebral  artery.     A  lesion  of  these  cortical  parts  causes  paralysis 


*  Brown-Sequard,  Dublin  Quart.  Journ.,  ilay,  1865. 
f  Gowers,  Diseases  of  the  Nervous  System,  1888. 


104  MEDICAL    DIAGNOSIS. 

of  voliintaiy  motion  without  loss  of  sensation.  The  hemiplegia  is 
more  or,  less  eomplete  aeeording  to  the  extent  of  the  motor  area 
involved.  It  is  on  the  opposite  side  to  that  of  the  disease,  and 
neither  the  nutrition  nor  the  electric  contractility  of  the  palsied 
muscles  is  impaired. 

The  cortical  hemiplegia,  when  sudden,  is  less  frequently  accom- 
panied by  loss  of  consciousness,  is  rarely  complete  from  the  first, 
affecting,  perhaps,  at  the  onset  only  the  face,  an  arm,  or  a  leg,  and 
is  soon  followed  by  rigidity  of  the  palsied  parts.  But,  on  the 
other  hand,  it  is  more  apt  to  be  transitory,  to  show  slighter  dif- 
ferences in  temperature  between  the  two  sides,  and  to  be  accom- 
panied by  localized  pain  in  the  head,  which  may  be  elicited  by 
percussion  over  the  seat  of  lesion.*  Limited  palsies,  monoplegias, 
are  much  more  common  in  disease  of  the  cortex  than  in  disease 
of  deeper  parts.  The  leg  alone  is  affected  in  lesions  of  the  medial 
cortex  or  those  near  to  the  longitudinal  fissure.  Irritative  lesions 
of  the  cortex  have  as  their  most  characteristic  sign  unilateral  con- 
vulsions. In  disease  of  the  middle  third  of  the  central  convolu- 
tions the  convulsions  generally  begin  in  the  hand. 

Lesions  confined  to  any  one  of  the  gray  central  ganglia,  where 
the  internal  capsule  is  not  involved,  do  not  afford  any  special 
feature  by  which  they  may  be  recognized  from  common  cerebral 
hemiplegia.  There  is  paralysis  of  motion  only,  which,  Charcot  f 
tells  us,  is  generally  transitory.  If  the  anterior  two-thirds  of  the 
capsule  be  involved,  the  palsy  is  still  exclusively  of  motion, 
though  it  is  more  or  less  persistent,  and  ultimately  accompanied 
by  muscular  contractions ;  if  the  posterior  third  of  the  capsule 
be  also  involved,  we  have  in  addition  cerebral  hemiansesthesia. 
Smell  may  also  be  lost  on  the  anaesthetic  side,  and  hemianopsia 
be  met  with.  In  disease  of  the  angle  and  posterior  segment  of 
the  internal  capsule  we  have  hemiplegia  of  the  ordinary  type. 
Indeed,  it  is  the  opinion  of  Gowers|  that  in  palsy  due  to  lesion 
of  the  corpus  striatuin  the  hemiplegia  is  permanent  only  if  the 
internal  capsule  is  involved  in  the  damage. 

A  lesion  of  one  opAic  tract  or  of  the  cortical  visual  centre  in  the 
occipital  lobe  will  cause  bilateral  hemianopsia ;  a  similar  effect  is 

*  Ferrier,  Localization  of  Cerebral  Disease,  1879. 

f  Lectures  on  Localization  in  Diseases  of  the  Brain,  New  York,  1878. 

X  Diseases  of  the  Nervous  System. 


DISEASES    OF   THE    BRAIN    AND    SPINAL    COIID.  105 

sometimes  produced  by  a  lesion  of  the  corpora  geniculata.  There 
may  be  considerable  hebetude,  but  no  other  marked  sym]>tom  of 
an  affection  of  the  brain  except  hemianopsia.  In  lesions,  also, 
of  the  prsefrontal  lobes,  that  part  which,  in  its  relation  to  the 
skull,  is  roughly  bounded  by  the  coronal  suture,  there  is  no  dis- 
order either  of  mobility  or  of  sensibility.  The  manifestations  are 
simply  those  of  restlessness  and  unsteadiness  of  mind,  impair- 
ment of  judgment  and  reason,  and  other  psychical  disturbances. 
There  is  no  motor  paralysis  except  of  the  foot.  Late  in  the  case, 
among  pressure  and  invasion  symptoms,  we  may  find  motor 
aphasia,  nystagmus,  and  unilateral  convulsions.*  In  disease  of 
the  temporo-sphenoidal  lobe  we  have  deafness  in  the  ear  opposite 
to  the  lesion,  and  sometimes  convulsions  with  preceding  auditory 
aura.     There  is  no  hemiplegia. 

The  nature  of  the  paralyzing  lesion,  the  pathological  diagnosis, 
can  be  arrived  at  only  by  a  careful  scrutiny  of  all  the  facts  of 
the  case.  A  sudden  paralysis  occurring  simultaneously  with  coma 
almost  always  has  its  origin  in  an  apoplectic  effusion,  more  rarely 
in  cerebral  embolism  ;  a  sudden  paralysis  without  coma  is  gen- 
erally due  to  a  rapid  giving  way  of  a  softened  brain  or  to  plug- 
ging of  the  vessels.  A  gradual  development  of  palsy  indicates 
some  chronic  cerebral  disorder,  such  as  softening,  or  a  tumor,  or 
any  affection  compressing  the  nervous  substance.  We  may  also 
gain  much  knowledge  by  carefully  exploring  the  organs  of  circu- 
lation and  the  kidneys.  Thus,  a  paralysis  found  to  be  conjoined 
to  a  cardiac  malady  or  to  a  diseased  state  of  the  arteries  is,  in 
all  likelihood,  owing  to  a  clogging  of  one  of  the  cerebral  arteries 
or  to  softening.  When  the  kidneys  are  seriously  disordered,  it  is 
likely  to  be  the  hemiplegia  caused  by  some  chronic  disease  of  the 
brain  or  its  vessels,  the  result  of  the  altered  nutrition  produced  by 
the  ill-purified  blood. 

A  further  clue  to  the  character  of  the  cerebral  lesion  is  obtained 
by  examining  the  palsied  muscles.  Tocld^  has  taught  us  that 
when  the  paralyzed  limbs  exhibit  a  rigid  state  from  the  moment 
of,  or  soon  after,  the  attack,  we  may  from  the  early  rigidity  assume 
the  lesion  to  be  of  an  irritative  nature,  such  as  an  inflammation, 


*  Mills,  Cerebral  Localization  in  its  Practical  Kelations,  1889. 
f  Clinical  Lectures  on  the  Nervous  System. 


106  MEDICAL    DIAGNOSIS. 

or  a  compression  of  healthy  brain-tissue  bv  an  apoplectic  clot  or 
by  an  acyuniulation  of  purifonn  fluid  in  the  subarachnoid  spaces. 
When  the  muscular  contraction  docs  not  take  place  u.ntil  late  in 
the  com})laint,  late  rigiditii,  and  becomes  associated  with  wasting 
of  the  muscles,  he  holds  it  to  be  caused  by  irritation  from  an  at- 
tempt at  cicatrization.  The  opinion  of  the  day  connects  this 
late  rio-idity  with  a  descending  sclerosis  of  the  motor  tracts.  It 
depends  on  active  mnscular  contracture,  and  lessens  during  sleep 
and  if  the  limb  be  soaked  in  hot  Avater.  It  is  generally  asso- 
ciated with  excessive  tendon  reflexes.  Under  excitement  the 
paralyzed  arm  and  leg  may  be  strongly  flexed,  and  automatic 
moveineuts  may  occur  when  the  patient  sneezes.* 

When  hemiplegia  has  been  of  long  standing,  late  rigidity  may 
be  combined  with  atrophy  of  the  muscles  and  other  nutritive 
changes  that  bespeak  a  secondary  degeneration,  spreading  into 
the  opposite  lateral  column  of  the  spinal  cord  ;  also  tremors,  as- 
sociated not  unusually,  as  Charcot  tells  us,  with  diminution  of 
sensibility  on  the  palsied  side ;  attacks  of  true  si)asms,  happening 
particularly  in  the  arms ;  and  choreic  movements,  a  condition  to 
which,  under  the  name  of  "  post-j^aralytic  chorea,"  Weir  JNIitchell  f 
especially  has  called  attention.  In  some  cases  of  hemiplegia 
there  is  much  pain  in  the  stricken  limb.  The  pain  may  precede 
returning  motion,  and  is  thus  of  favorable  augury.  But  in  limited 
disease  of  the  internal  capsule  affecting  the  sensory  path  the  pain 
in  the  palsied  limbs  may  jiersist  through  life. 

Hemiplegia  may  be  feigned,  %  But  the  results  of  electricity, 
especially  where  altered  sensibility  as  well  as  defective  motion  is 
simulated,  and  the  test  proposed  by  Hughlings  Jackson,  that  the 
arms  do  not,  as  in  real  hemiplegia,  fall  forward  when  the  patient 
stoops,  but  are  retained  at  the  side,  will  usually  detect  the  fraud. 

MOXOPLEGIA. 

When  Ave  have  limited  lesions  we  have  limited  palsies,  and 
researches  on  localization  are  teaching  us  more  and  more  accu- 
rately to  recognize  the  centres  affected  in  these  palsies  of  special 

*  Eoss,  Diseases  of  the  Nervous  System,  1883,  vol.  i.  p.  187. 

f  Amer.  Journ.  3Ied.  Sci.,  Oct.  1874. 

:j;  For  an  instructive  case,  see  London  Lancet,  April,  187-4. 


DISEASES    OF    THE    BRAIN    AND    SPINAL   OOIID.  107 

parts,  or  of  one  limb,  or  of  a  group  of  movements.  Of  course, 
in  making  a  diagnosis  of  the  paralysis  being  due  to  disturbance 
of  a  special  nerve-centre,  we  must  be  careful  to  exclude,  as  the 
cause  of  the  local  palsy,  peripheral  affections,  and  those  in  the 
course  of  the  nerve  supplying  the  stricken  part,  and  also  to  make 
it  clear  that  the  lesion  is  not  spinal  of  very  circumscribed  kind. 
In  monoplegias  the  palsy  is  never  complete.  Furthermore,  it  is 
always  important  to  endeavor  in  a  given  case  to  separate  the 
symptoms  which  may  be  due  to  invasion  of  or  to  pressure  on 
adjacent  centres  from  the  localizing  symptoms  of  the  main  lesion. 
Let  us  now  take  up  some  of  the  limited  palsies  dependent  on 
cerebral  disease,  especially  in  the  motor  areas  of  the  cortex. 

One  arm  only  is  ■  paralyzed. — Here  we  find  the  lesion  in  the 
ascending  parietal  and  the  ascending  frontal  convolution  on  the 
side  opposite  to  the  palsy,  and  the  disease  is  limited  to  the 
middle  third  of  the  convolutions.  ,  If  the  lesion  be  double,  as 
in  a  case  referred  to  by  Bourdon,*  both  arms  are  helpless.  But, 
whether  single  or  double,  with  the  damaged  motion  there  are 
unimpaired  sensation  and  electro-motor  contractility.  Disease 
of  the  ascending  frontal  opposite  the  upper  half  of  the  inferior 
frontal  convolution  gives  rise  to  palsy  of  the  lower  part  of  the 
face  except  the  lips. 

One  arm  and  the  same  side  of  the  face  are  paralyzed. — In  this 
"  brachio-facial  monoplegia"  the  lesion  is  in  the  central  region  of 
the  cortex,  toward  the  middle  or  lower  third  of  the  ascending  con- 
volutions in  the  facial  and  arm  centres.  It  is  a  pure  motor  palsy, 
associated,  however,  usually  with  aphasia  when  the  disease  is  left- 
sided.  The  main  movements  of  the  muscles  of  the  upper  part  of 
the  arm  are  kept,  while  those  of  the  hand  are  lost.  Palsy,  of 
cerebral  origin,  limited  to  one  side  of  the  face,  without  the  arm 
being  implicated,  is  rare ;  the  cortical  disease  is  in  the  centre  for 
the  facial  region.  The  affection  is  usually  left-sided,  and  is  apt 
to  become  complicated  with  aphasia.  The  lower  part  of  the 
face  bears  the  brunt  of  the  palsy ;  unlike  Bell's  palsy,  the  orbi- 
cularis and  the  upper  part  of  the  face  are  but  little,  if  at  all, 
disturbed  ;t  further,  there  is  no  disease  of  the  temporal  bone  to 

*  Bull.  Soc.  Anat.,  1874. 

t  This  was  strikingl}'  illustrated  in  a  case  reported  by  Guiteras,  Phila.  Med. 
Times,  Nov.  1878. 


108  MEDICAL    DIAGNOSIS. 

explain  the  localized  palsy  l)y  an  injurv  to  the  facial  nerve.  The 
tongue  ii?  also  very  generally  implicated. 

The  leg  only  is  paralyzed. — This  is  a  very  rare  form  of  paral- 
ysis, and  presupposes  a  lesion  limited  to  the  motor  centre  for 
the  leg.  The  centre  for  the  leg  and  foot  is  fixed  by  the  recent 
researches  of  Horsley  and  Schaefer  as  in  the  posterior  central 
and  the  postero-parietal  lobule.  In  some  of  these  cases  of  ''  crural 
monoplegia"  on  record  the  ascending  parietal  and  postero-parietal 
conv(.)lutions  have  been  found  diseased.  Sensation  is  not  affected  ; 
the  arm  is  apt  to  become  gradually  involved  in  the  palsy  :  in 
Ferrier's  case*  the  lesion  was  in  the  quadrilateral  lobule  on  the 
internal  aspect  of  the  hemisphere  and  the  upper  extremity  of  the 
ascending  parietal  and  frontal  convolutions. 

There  are  many  other  kinds  of  limited  palsies  of  cerebral 
origin,  such  as  of  the  tongue,  glossoplegia,  of  the  face  and  tongue, 
facio-lingual  monoplegia,  of  the  eye  muscles,  oculo-motor  mono- 
plegia, and  one-sided  blindness,  hemianopsia,  to  all  of  which 
I  can  only  refer,  since  our  knowledge  is  not  definite  enough  to 
lay  down  concise  conclusions  for  diagnosis.f  In  part,  too,  they 
will  be  discussed  farther  on.  It  must,  however,  be  added  that  in 
all  these  limited  palsies  traceable  to  disease  of  the  brain  we  are  apt 
to  have  such  symptoms  as  are  common  in  brain  affection, — head- 
ache, giddiness,  and  the  like.  These  aid  us  in  understanding  the 
nature  of  the  disorder. 

Perhaps,  too,  we  shall  receive  help  from  a  means  of  diagnosis 

*  Brain,  vol.  iii.,  1880. 

f  As  bearing  on  tliese  and  other  matters  connected  with  localization,  see 
especially  the  works  of  Ferrier  and  Charcot  referred  to ;  Hitzig,  in  Klinische 
Vortrage ;  many  papers  in  the  Archives  de  Physiologic,  in  the  West  Eiding 
Reports,  and  in  Krain  ;  Hughlings  Jackson,  Clinical  and  Physiological  Ke- 
seai'ches  on  the  Nervous  System ;  Pitres,  Lesions  du  Centre  Ovale,  and  papers 
with  Charcot,  Revue  de  Med.,  1879  and  1883  ;  Nothnagel,  Topische  Diagnostik 
der  Gehirnkrankheiten,  Berlin,  1879  ;  Exner,  Untersuchungen  iiber  die  Locali- 
sation der  Functionen  in  der  Grosshirnrinde,  Wien,  1881  ;  Ross,  Diseases  of  the 
K'ervous  System,  vol.  ii.,  1883  ;  Govvers,  Diseases  of  the  Nervous  System,  1888  ; 
Seguin,  Amer.  Journ.  Med.  Sci.,  vol.  xcvi.,  1888  ;  Allen  Starr,  Amer.  Journ. 
Med.  Sci.,  1884  and  1885, — containing,  besides  other  valuable  matter,  in  July 
number,  1884,  the  collected  American  cases  of  Cortical  Lesions, — also  Medical 
Record,  Feb.  1886 ;  Mills,  Cerebral  Localization  in  its  Practical  Relations, 
Transactions  of  the  Congress  of  American  Physicians  and  Surgeons,  vol.  i., 
1889  ;  Hoi-sley  and  Schaefer,  PJiilos.  Transact.  Roy.  Soc,  1888. 


DISEASES   OF   THE   BRAIN   AND   SPINAL   CORD.  109 

inaugurated  by  Broca, — cerebral  thermometry  ;  and  a  higher  local 
temperature  will  point  to  the  region  affected.  But  the  observa- 
tions are  not  as  yet  definite  enough  to  warrant  their  adoption,  and 
what  makes  them  very  difficult  of  application  is,  that  the  temper- 
ature of  distant  parts  has  been  found  to  be  influenced  by  excita- 
tion of  the  surface,  and  that  the  difference  in  the  disease  itself 
materially  modifies  the  temperature  of  the  head.  Thus,  in  embo- 
lism* we  have  a  lower  temperature  over  the  part  which  ought  to 
be  supplied  by  the  occluded  vessel ;  in  inflammation  and  tumor 
and  abscess  the  temperature  is  higher.  Again,  as  we  know  par- 
ticularly by  the  elaborate  researches  of  Lombard,  emotional  ac- 
tivity, as  well  as  or  even  more  than  intellectual  work,  causes  a  rise 
of  temperature,  the  rise  sometimes  exceeding  0.18°  Fahr.  (0.1° 
Cent.).  Active  exercise,  Amidon  states,  may  do  the  same.  Thus 
the  patient  should  be  examined  when  free  from  excitement  and  at 
rest.  Various  portions  of  the  head  must  be  selected  as  points  for 
the  application  of  the  surface  thermometer,  and  the  corresponding 
regions  compared.  The  chief  regions  are,  on  each  side,  the  frontal ; 
the  parietal ;  the  occipital ;  the  vertical ;  the  side  of  the  head,  in 
a  line  below  the  vertex,  and  above  the  frontal,  parietal,  and  occip- 
ital stations ;  and  the  upper  section  of  the  entire  head,  on  the 
curve  front  and  back  above  this  line.  For  comparison  we  must 
remember  that  the  frontal  region  in  health  on  the  left  side,  which 
always  registers  more,  gives,  Broca  tells  us,  95.7°  Fahr.  (35.43° 
Cent.);  the  parietal,  91.49°;  Gray  records,  in  accordance  with 
Broca,  the  left  occipital  region  as  92.66°.  The  fact  has  already 
been  alluded  to  that  Maragliano  and  Seppili,  making  their  obser- 
vations in  summer,  give  the  mean  normal  temperature  as  higher 
by  nearly  two  degrees  Fahr,  It  is  so  in  the  frontal  regions,  and 
in  the  occipital  region  the  difference  is  much  greater.  These 
authors  tell  us  that  in  the  insane  the  temperatiu*e  varies  much 
according  to  the  form  of  insanity.  The  highest  temperature  is 
found  on  the  left  half  of  the  head,  and  not  materially  different  on 
the  left  frontal  region,  in  furious  mania,  36.9°  Cent.  (98.4°  Fahr.); 
in  progressive  paralysis,  36.6°  (97.9°  Fahr.)  ;  in  imbecility,  idiocy, 
and  simple  mania,  36.3°  (97.3°  Fahr.) ;  in  simple  dementia,  36° 
(96.8°  Fahr.).     In  locating  brain  tumors  several  observers  have 

*  Broca,  Bulletin  de  rAcademie  de  Medecine,  Dec.  1879. 


110  MEDICAL    DIAGNOSIS. 

ninde  use  of  tlic  thcrniomoter.  Gray*  cites  a  case,  and  Mills f 
and  Segujn|  have  published  several  instances;  Eskridge§  has  re- 
corded some  elaborate  studies  of  the  head  temperature  in  abscess 
and  tubercular  inflammation.  On  the  whole,  the  head  tempera- 
tures are  more  steady  tlian  those  taken  in  the  axilla. 

PARAPLEGIA. 

This  differs  from  hemipleoia  in  the  palsy  occurrino-  on  both 
sides,  yet  being,  in  the  vast  majority  of  instances,  limited  to  the 
loAvcr  extremities.  Its  almost  invariable  cause  is  a  lesion  of  the 
spinal  cord.  In  truth,  if  we  call  hemiplegia  paralysis  from  brain 
disease,  we  may  call  paraplegia  paralysis  from  spinal  disease. 
Paraplegia  is  generally  due  to  a  marked  organic  lesion  ;  but  there 
are  cases  in  which  it  exists  independently  of  any  recognizable 
structural  change,  and  in  which  it  results  from  poisons,  from 
fatigue,  from  excesses. 

The  disorder  generally  comes  on  slowly.  At  first  the  patient 
only  loses  the  steadiness  of  his  gait ;  gradually  he  is  deprived  of 
all  power  of  motion,  but  the  intellect  and  the  nerves  of  special 
sense  remain  unaffected.  If  the  lesion  be  in  the  lumbar  part  of 
the  cord,  the  palsy  is  confined  to  the  loAver  extremities  and  to 
the  pelvic  muscles ;  if  the  dorsal  portion  be  attacked,  we  find,  in 
addition,  signs  of  paralysis  of  the  abdominal  walls  and  of  the 
sphincters,  tympanites,  and  somewhat  impeded  breathing.  In 
diseases  of  the  upper  section  of  the  cord  there  is  coexisting  palsy 
of  the  upper  extremities,  with  dilated,  sluggish  pujDils,  and  diffi- 
culty in  deglutition  and  in  respiration.  In  the  muscles  supplied 
by  the  nerves  which  originate  in  healthy  marrow,  involuntary 
retractions  or  reflex  phenomena  may  be  induced,  are,  indeed,  gen- 
erally exaggerated,  and  the  striking  effects  of  strychnine,  when 
given  in  doses  sufficient  to  produce  its  peculiar  muscular  spasms, 
are  manifested.     The  palsied   muscles,   in   the  majority  of   the 

*  New  York  Medical  .Journal,  Aug.  1878,  and  Chicago  Journal  of  Mental 
and  Nervous  Diseases,  Jan.  1879. 

t  Phila.  Medical  Times,  Jan.  1879,  and  New  York  Medical  Kecord,  Aug. 
1879. 

J  Amer.  .Journ.  Med.  Sci.,  vol.  xcvi.,  1888. 

^  Transactions  of  the  College  of  Physicians  of  Philadelphia,  Third  Series, 
vol.  vi.,  1883. 


DISEASES   OF   THE   BRAIN   AND   SPINAL   CORD.  Ill 

afFections  occasioning  tiie  paraplegia,  do  not  respond  to  the  elec- 
trical stimulus. 

Paraplegia  is  generally  more  marked  on  one  side  than  on  the 
other,  and  the  paralysis  of  motion  is  apt  to  be  associated  with 
complete  anaesthesia.  When,  as  sometimes  happens,  the  mischief 
is  limited  to  a  lateral  segment  of  any  part  of  the  cord,  there  is 
paralysis  of  motion  on  the  same  side  of  the  body,  and  of  sensation 
on  the  other.  Preceding,  or  even  attending,  many  cases  of  para- 
plegia, is  a  symptom  which  belongs  exclusively  to  affections  of 
the  cord  :  a  spasm  of  the  flexor  muscles  of  the  lower  limbs,  so 
powerful  that  the  anterior  parts  of  the  thighs  come  almost  in 
contact  with  the  abdomen,  while  the  heels  are  drawn  up  so  as  to 
touch  the  back  of  the  thighs.* 

Let  us  now  take  a  cursory  view  of  the  different  forms  of  spinal 
paraplegia. 

SUDDEN    PARAPLEGIA. 

Spinal  Hemorrhage. — Sometimes  the  paralysis  occurs  sud- 
denly, and  in  consequence  of  an  injury  to  the  spine,  of  a  displace- 
ment subsequent  to  a  disease  of  the  bones,  of  blood  extravasated 
into  the  canal,  of  poisons,  as  the  lathyrus  sativus,t  or  of  bulbar  or 
spinal  disorder  from  sudden  displacement  of  the  cerebro-spinal 
fluid  following  blows  on  the  head.i  When  either  of  the  former 
two  causes  has  led  to  the  sudden  palsy,  the  diagnosis  is  materially 
aided  by  the  history  of  the  case,  and  by  a  close  examination  of 
the  vertebral  column.  But  if  there  be  no  signs  of  a  disease  of 
the  bones  or  of  the  intervertebral  cartilages,  we  may  suspect  a 
spinal  hemorrhage  to  have  produced  the  sudden  and  complete 
paraplegia,  or  the  palsy  which,  though  at  first  partial,  rapidly 
becomes  complete ;  and  this  suspicion  becomes  much  strengthened 
if  violent  localized  pain  in  the  back  exist  or  have  preceded  the 
rapidly  developed  palsy,  if  the  patient  be  unable  to  retain  his 
urine  or  fseces,  and  if  the  affected  limbs  be  relaxed  and  largely 
deprived  of  sensation.  These  are  the  symptoms  of  apoplexy  of 
the  cord.     The  seat  of  pain  corresponds  to  the  seat  of  bleeding. 

*  Brown-Sequard's  Lectures  on  the  Nervous  Centres,  p.  114. 
t  Irving,  Indian  Annals,  No.  12,  referred  to  in  Brit,  and  For.  Med.-Chir. 
Kev.,  Oct.  1860. 

:j:  Duret,  Traumatismes  cerebraux,  Paris,  1878. 


112  MEDICAL    DIAGNOSIS. 

The  pain  occurs  in  distressing  paroxysms  and  passes  along  the 
course  of  the  nerves  compressed  by  the  extravasation.  Where 
the  hemorrhage  is  meningeal,  there  is  more  persistent  pain,  with 
rigidity  of  the  spine,  spasms  of  the  legs,  slighter  disturbance  of 
sensibility,  and  far  less  and  less  quickly  increasing  paralysis,  and 
there  is  more  apt  tt)  be  spasmodic  retention  of  urine.  Tiie  absence 
of  early  fever  distinguishes  the  spinal  hemorrhage  from  spinal 
meningitis ;  subsequent  fever  bespeaks  the  occurrence  of  this  as  a 
complication.  The  muscular  spasm  is  sometimes  so  severe  that  it 
has  been  mistaken  for  tetanus,  which  lacks  the  violent  pain  in  the 
back.  The  most  common  causes  of  spinal  hemorrhage  are  blows 
and  falls  on  the  back  or  falls  on  the  feet.  It  is  also  met  with 
in  diseases  with  hemorrhagic  tendencies,  in  convulsive  affections, 
and  in  the  course  of  myelitis. 

But,  besides  these  causes,  others  lead  rapidly  to  paraplegia. 
Softening  of  the  cord  may  have  progressed  latently  until  the  de- 
generation destroys  the  continuity  of  the  conducting  tubules,  when 
palsy  at  once  takes  place.  Then  there  are  cases  follo\ying  sexual 
excesses,  cases  for  which  neither  during  life  nor  after  death  can 
an  organic  cause  be  assigned,*  and  which  must  therefore  be  viewed 
as  due  to  enfeeblement  of  functional  power.  Similar  cases  of 
spinal  paralysis,  more  or  less  complete,  may  occur  after  fatigue 
and  violent  exercise.  In  all  instances  of  s]iinal  palsy  due  to  im- 
paired nerve-power — or  spinal  paresis,  as  Handficld  Jones  f  has 
termed  this  affection — the  disorder  is  much  more  apt  to  come  on 
quickly  than  gradually,  and  a  tonic  treatment  is  likely  to  be  fol- 
lowed by  decidedly  good  eifects.  But  in  regard  to  all  these  cases 
of  functional  palsy,  the  same  as  in  regard  to  reflex  palsies,  science 
is  clearly  narrowing  their  number  by  finding  some  organic  affection 
in  the  cord,  often  S'i'condary  to  an  ascending  neuritis. 

Acute  Ascending  Paralysis. — Yet  another  variety  of  para- 
plegia which  may  happen  rapidly  is  that  form  which  has  been 
described  as  acute  ascending  paralysis,  or  Landry's  paralysis.  It 
may  come  on  after  fatigue  and  exposure  in  persons  in  perfect 
health,  generally  in  men  between  twenty  and  forty  years  of  age. 


*  For  instance,  Case  XVIII.  in  Gull's  series  in  Guy's  Hosp.  Eep.,  vol.  iv., 
3d  Series. 

t  Functional  Nervous  Disorders. 


DISEASES   OF   THE   BRAIN"   AND   SPINAL   CORD.  113 

Usually  there  is  little  or  no  fever  except  at  the  onset.  Numl)ncss 
and  tingling,  and  slight  pain  in  the  lower  extremities,  are  soon  fol- 
lowed by  loss  of  muscular  })ower,  which,  in  turn,  goes  on  rapidly, 
generally  in  a  few  days,  to  complete  paraplegia.  The  legs  are  re- 
laxed and  immovable,  the  muscles  of  the  trunk  are  next  aifected, 
then  the  upper  extremities  become  implicated,  and  sensation,  which 
at  first  was  normal,  is  somewhat  enfeebled,  though  never  to  a 
marked  degree ;  occasionally  the  arms  are  involved  before  the 
legs.  The  patient  is  restless,  sleepless,  but  his  intelligence  is  un- 
impaired, and  we  find  no  bedsores  and  no  palsy  of  the  bladder  or 
rectum.  The  respiration  and  circulation  are  in  the  progress  of  the 
disease  apt  to  become  embarrassed,  there  is  acute  enlargement  of 
the  spleen,  and  sudden  death  ensues  within  a  month  from  the 
time  of  the  seizure,*  or,  indeed,  the  case  may  end  fatally  in  less 
than  a  week.  But  all  cases  do  not  run  so  rapid  a  course ;  and, 
in  truth,  we  meet  with  instances  in  which  the  disorder  is  rather 
chronic  than  acute,  or  is  arrested.  The  muscles  do  not  atrophy, 
and  their  electrical  excitability  is  unimpaired,  which  is  a  very 
valuable  diagnostic  test.  About  the  reflexes  the  statements  are 
conflicting.  It  is  most  likely  that  at  first  both  the  superficial 
and  the  deep  reflexes  are  absent,  and  that  they  do  not  return,  cer- 
tainly the  knee-jerk  does  not,  excej)t  when  the  paralysis  passes 
away.  Jaccoudf  tells  us  that  in  the  cases  he  observed  the  reflex 
movements  werfe  abolished.  The  disease  which  most  resembles 
acute  ascending  paralysis  is  acute  progressive  or  multiple  neu- 
ritis. But  here  sensation  is  rapidly  lost,  and  so  is  the  electrical 
excitability. 

Multiple  Neuritis, — When  nerve  after  nerve  rapidly  in- 
flames, or  the  inflammation  occurs  at  one  time,  an  extensive 
palsy  is  quickly  developed,  the  nature  of  which  we  have  only  of 
late  years  recognized.  The  disease  is  an  affection  of  the  peripheral 
nerves,  though  it  has  the  misleading  symptoms  of  a  spinal  malady. 
It  attacks  both  sexes,  is  most  common  between  the  ages  of  thirty 
and  fifty,  and,  though  it  may  follow  altered  blood-states  or  rheu- 
matism, or  be  due  to  exposure,  by  far  its  most  frequent  cause 

*  As  in  the  case  reported  by  Hayem,  Travaux  de  la  Societe  Medicale 
d'Observation,  tome  ii.,  1867;  see  also  Leyden's  Klinik  der  Eiickenmarks- 
krankheiten. 

f  Clinique  Medicale. 


114  MEDICAL    DIAGNOSIS. 

is  chronic  alcoholism.  It  lias  generally  an  acute  or  a  subacute 
beginnijig,  with  decided  increase  in  temperature.  At  first  vague, 
then  more  decided  pains  are  felt  in  the  extremities,  chiefly  in  the 
fingers  and  toes,  and  these  pains  soon  become  darting  or  burning. 
The  pain  is  often  preceded  by  tingling,  is  increased  by  motion, 
and  is  associated  with  tenderness  of  the  affected  nerve-trunks  and 
with  both  skin  and  muscle  tenderness  of  the  parts  to  which  they 
are  distributed ;  finally  this  increased  sensibility  may  give  Avay 
to  anaesthesia. 

The  palsy  shows  itself  generally  first  in  the  arms,  the  earliest 
loss  of  power  manifesting  itself  in  the  extensors  of  both  sides. 
Soon  the  muscular  weakness  is  seen  also  in  the  legs,  and  the 
trunk  muscles  and  face  muscles  may  become  involved.  The 
symmetrical  character  of  the  palsy  is  very  noticeable,  as  are  also 
the  wrist-drop  and  the  foot-drop.  The  parts  affected  waste,  and 
lose  their  reflex  excitability  ;  the  loss  of  the  knee-jerk  is  especially 
pronounced.  The  muscles  do  not  react  to  faradization,  though 
they  may  to  the  galvanic  current ;  often,  indeed,  they  present  the 
reaction  of  degeneration  :  the  nerves  are  uninfluenced  by  the 
electric  stimulus.     Qildema  of  the  arms  and  legs  is  frequent. 

The  disease  may  run  on  to  complete  palsy  of  the  limbs  in  less 
than  two  weeks,  and  death  result  from  paralysis  of  the  I'espiratory 
muscles ;  or  the  affection  may  pass  into  a  chronic  condition,  and 
a  slow  improvement,  with  return  of  power  in  the  muscles,  take 
place.  The  diagnosis  is  generally  easy.  The  tingling  in  the 
extremities,  the  cutaneous  and  muscular  tenderness,  and  the  early 
development  of  muscular  weakness,  distinguish  the  disease  from 
rheumatism.  In  some  instances,  where  it  is  dtfficult  to  elicit  ten- 
derness of  nerve-trunks,  or  where  this  symptom  is  wanting,  where 
the  muscular  tenderness  is  not  marked,  and,  moreover,  the  palsy  is 
slight  and  incoordination  of  movement  is  observed,  the  similarity 
to  locomotor  ataxia  is  great,  and  the  eye-symptoms  of  this  affection 
alone,  if  present,  will  help  to  a  correct  conclusion.  In  ordinary 
cases  the  greatest  resemblance  is  to  those  instances  of  acute  myelitis 
which  run  a  rapid  course,  and  especially  those  in  which  muscular 
wasting  is  marked.  To  acute  ascending  paralysis  intense  cases  of 
the  disease  also  bear  a  strong  likeness. 

In  the  following  tal)le  are  contrasted  the  features  of  multiple 
neuritis,  of  acute  myelitis,  and  of  acute  ascending  paralysis. 


DISEASES   OF   THE   BRAIN   AND   SPINAL   CORD. 


115 


Multiple  Neuritis. 

Fever,  with  at  first  de- 
cided elevation  of  tem- 
perature. 

Palsy  begins  in  forearms, 
extends  to  legs  and 
trunk. 

Muscles  atrophy.  Tro- 
phic changes  in  skin 
and  nails  common. 

Marked  pain  and  sensory 
disturbances,  hyperses- 
thesia  especially,  later 
anaesthesia  in  the  ai'ea 
of  distribution  of  the 
inflamed  nerves. 

Loss  of  electrical  excita- 
bility. Generally  the 
reaction  of  degenera- 
tion. 

Reflex  action  always  lost. 


Sphincters  unaffected. 

No  bulbar  symptoms, 
though  respiratory 
palsy  may  happen. 

Mental  derangement  com- 
mon. 


,,  Acute   Ascenbiko 

Acute  Myelitis.  Paralysis. 

Fever   generally    moder-  Slight,  if  any,  elevation 

ate.  of  ternperatui-Ci 


Palsy  generally  affects 
only  legs  and  lower 
part  of  trunk,  though 
it  may  affect  arms. 

Muscles  atrophy  rapidly. 

Trophic  changes  marked. 


Paralysis  rapidly  ex- 
tending from  lower 
extremities  ;  relaxed 
muscles. 

No  muscular  atx•oph3^ 


No  pain  ;  complete  anses-  No  marked  pain  or  more 

thesia     below     lesion  ;  than  dulling  of  sensa- 

zones  of  hypersesthesia  tion  in  affected  parts, 
corresponding  to  lesion. 


Loss  of  electrical  excita- 
bility ;  certainly  to  far- 
adization. 

Excessive  reflex  action, 
except  in  parts  deriving 
nerve-supply  from  in- 
jured centres,  there  lost. 

Sphincters  affected  early  ; 
bedsores. 

Bulbar  symptoms  rare ; 
failure  of  respiratory 
power  may  happen. 

Mind  unaffected. 


GRADUAL    PARAPLEGIA. 


No  change  in  electrical 
excitability. 


Absence  of  reflexes  the 
rule. 


Sphincters  nearly  always 
escape ;  no  bedsores. 

Bulbar  symptoms  fre- 
quent. 

Mind  remains  clear. 


This  occurs  in  congestion,  in  acute  and  chronic  inflammation 
of  the  meninges,  in  myelitis,  in  softening,  in  atrophy,  in  sclerosis, 
in  compression  of  the  cord,  and  from  reflex  irritation.  These  are 
some  of  the  marks  of  discrimination  : 

Spinal  Congestion. — In  congestion  of  the  cord  there  is  dull 
pain,  generally  confined  to  the  lumbar  and  sacral  regions ;  the 
palsy  progresses  slowly  from  below  upward,  is  preceded  by  aching 
in  the  legs,  by  tingling,  by  numbness,  is  incomplete,  and  is  not 
combined  with  paralysis  of  the  sphincters.  Moreover,  the  diffi- 
culty in  walking  is  much  greater  on  arising  after  a  night's  rest, 
or  indeed  whenever  the  patient  has  been  for  any  length  of  time  in 


1]6  MEDICAL    DIAGNOSIS. 

the  recinnbcnt  posture.  AVe  may  often,  too,  trace  the  congestion  to 
soi]ie  distiu-bance  of  the  circukition,  especially  of  the  abdominal 
circulation ;  or  to  alterations  in  the  composition  of  the  blood,  as 
in  rheumatism,  smallpox,  or  typhus ;  or  we  find  it  as  a  result  of 
exposure  to  cold  and  wet,  or  of  standing  for  a  l(ing  time,  or  as  a 
sequel  of  the  malarial  fevers. 

Spinal  Ansemia. — Similar  In  some  of  its  symptoms  to  spinal 
congestion,  though  very  dissimilar  in  its  causation,  is  so-called 
spinal  antemia.  A  disease  usually  of  young  females,  and  form- 
ing part  of  a  general  anaemic  condition,  or  following  exhausting 
discharges,  or  associated  witli  a  uterine  affection,  it  often  shows 
the  symptoms  of  liysterical  or  ''  irritable  S}>ine,"  or  "  spinal  irrita- 
tion." The  traits  distinguishing  this  malady  from  spinal  con- 
gestion are,  that  in  the  former  we  have  much  more  marked  signs 
of  head,  chest,  and  abdominal  distress,  such  as  vertigo,  palpitation, 
neuralgic  chest  and  abdominal  pains,  nausea,  and  other  dyspeptic 
symptoms.  The  inactive  or  slightly  palsied  limbs  often  ache, — 
though  affections  of  motility  are  far  from  constant, — are  not  in- 
frequently the  seat  of  spasms,  are  sensitive  to  tlie  touch,  act  better 
after  having  been  in  the  recumbent  posture ;  there  is  paii]  along 
the  spine,  and  pressure  on  the  spinous  processes  of  the  vertcbriB 
shows  marked  tenderness.  But  that  sjiinal  anaemia  is  the  deter- 
mining cause  of  the  symptoms  is  by  no  means  proved. 

Spinal  Meningitis. — In  inflammation  of  the  meninges  we 
encounter  severe  pain  in  the  back,  little  influenced  by  pressure 
upon  the  spine,  yet  aggravated  by  movement,  even  by  the  acts  of 
defecation  and  urination  ;  sometimes  a  sensation  as  if  a  cord  had 
been  drawn  around  the  belly  ;  pains  in  the  limbs  similar  to  those 
of  rheumatism  ;  cutaneous  hypersesthesia  or  anaesthesia ;  muscu- 
lar twitchings  and  contractions,  more  or  less  permanent  and  pain- 
ful ;  increased  superficial  and  deep  reflexes  when  the  disease  is 
above  the  lumbar  enlargement  of  the  cord,  and  very  commonly 
distressing  spasms  in  the  muscles  of  the  back,  and  spasms  in  tlie 
limbs  occasioned  fey  attempts  to  move  them  ;  rigidity  of  the  spinal 
column;  bedsores;  dyspnoea;  retention  of  urine  ;  yet  only  incom- 
plete paralysis,  or,  indeed,  none  at  all.  In  the  acute  form  we  have 
decided  fever.  When  marked  ]>ara]ilcgia  follows  the  symptoms 
mentioned,  we  may  susjaect  myelitis  or  that  an  effusion  has  taken 
place  which  compresses  the  spinal  cord.     Cases  of  spinal  menin- 


DISEASES   OP   THE   BRAIN   AND   SPINAL   CORD.  117 

o-itis  occur  from  falls  and  shocks,  and  from  exposure  to  cold  ; 
they  are  not  unusual  among  soldiers  who  have  slept  on  dani[) 
ground. 

As  regards  the  special  membranes  involved,  there  is  no  cer- 
tainty in  diagnosis.  The  symptoms,  save  in  the  acute  purulent 
forms  of  the  disease,  are  slow  in  developing.  In  inflammation  of 
the  dura  mater,  pachymeningitis,  the  radiating  pains  are  very 
severe,  but  there  is  less  vertebral  pain  and  stiffness  in  the  back  : 
these  signs  are  seen  in  their  fullest  expression  in  inflammation 
of  the  pia  mater  and  arachnoid.  In  inflammation  of  the  inner 
surface  of  the  dura  mater,  'pachymeningitis  spinalis  interna,  which 
particularly  happens  in  the  cervical  region,  the  symptoms  are 
chiefly  referred  thither ;  and  stiffness  of  the  neck,  paralysis  in  the 
upper  extremities,  especially  in  the  parts  supplied  by  the  median 
and  ulnar  nerves,  claw-like  hands,  contractions,  severe  pains  in 
the  arms,  spots  of  anaesthesia,  and  herpetic  eruptions  are  common. 
ki  a  later  period,  as  the  hypertrophic  thickening  of  the  dura 
mater  extends,  and  the  cord  is  more  and  more  compressed,  the 
lower  extremities  may  become  paralyzed.  There  is  a  hemorrhagic 
form  of  pachymeningitis  interna  having  the  same  causes  as  hsema- 
toma  of  the  dura  mater  of  the  brain,  and  often  accompanying  it. 

Myelitis. — Myelitis  presents  many  of  the  same  symptoms  as 
spinal  meningitis.  Frequently  they  come  on  by  slow  degrees,  and 
the  paraplegia  gi'adually  becomes  complete.  The  symptoms  are 
much  the  same  as  in  acute  myelitis,  though  slow  in  developing. 
There  is  strong  knee-jerk  and  ankle  clonus.  Contractions  of  the 
muscles  are  uncommon,  and  not  permanent,  unless  late  in  the 
disease ;  the  muscles  are  usually  flaccid ;  there  is  comparatively 
little  pain,  none  on  pressure  at  any  part  of  the  spine,  or  on  mo- 
tion, and  anaesthesia  sooner  or  later  shows  itself.  Further,  we 
generally,  though  not  constantly,  find  the  urine  alkaline,  and,  as 
a  rule,  a  want  of  control  over  the  bladder  and  rectum  exists,  bed- 
sores form  readily,  and  the  temperature  of  the  palsied  is  lower 
than  that  of  the  healthy  parts. 

In  acute  cases  there  are,  as  in  acute  spinal  meningitis,  with 
which,  indeed,  myelitis  may  be  complicated,  heat  of  skin  and  a 
frequent  pulse.  There  is  pain  in  the  back,  not  increased  by  move- 
ments, and  pain  in  the  limbs  preceded  by  numbness  or  burning. 
In  many  instances  we  notice  erection  of  the  penis.     Reflex  move- 


118  MEDICAL   DIAGNOSIS. 

ments  in  the  relaxed  jialsietl  limbs,  at  first  still  easily  excited, 
and  excited,  too,  by  irritation  elsewhere  applied,  are  gradually 
abolished  as  the  process  of  inflammation  and  softening  affects  the 
gray  matter  of  the  cord.  In  dorsal  myelitis  the  trunk  reflexes 
are  impaired,  but  the  reflex  excitability  remains  excessive  in 
the  parts  supplied  by  nerves  not  coming  from  the  greatly  dis- 
eased centres,  and  is  ao-o-mvated  by  descending^  deo-eneration  of 
the  motor  fibres.  In  disease  of  the  lumbar  enlargement  it  is 
wholly  lost. 

An  altered  sensibility  to  heat  and  cold,  when,  for  instance,  a 
sponge  soaked  in  Avarra  water  or  a  piece  of  ice  is  applied  to  the 
spine  over  the  inflamed  spot,  has  been  spoken  of  as  a  diagnostic 
test.  In  either  case  the  sensation,  when  the  diseased  part  is 
reached,  changes  to  a  burning  sensation.  This  symptom  is,  how- 
ever, far  from  constant,  and  cannot  be  accepted  as  conclusive. 
There  is  a  zone  of  hypersesthesia  at  the  level  of  the  lesion,  and 
corrcsjionding  to  this  a  zone  of  constriction  or  "girdle  pain." 
Below  the  level  of  the  lesion  the  loss  of  sensation  is  complete. 
The  paraplegia,  even  in  acute  cases,  is  not  suddenly  developed. 
Yet  we  meet  with  marked  exceptions.  There  are  instances  in 
which  it  comes  on  as  rapidly  as  in  spinal  hemorrhage,*  and 
without  attending  loss  of  sensibility  ;  or  a  paralysis  of  the  bladder 
is  the  first  symptom,  and  paralysis  of  motion  and  of  sensation 
quickly  follows,  f 

INIyelitis  may  be  the  result  of  cold  and  exposure,  of  over- 
exertion, of  syphilis,  of  peripheral  irritation,  of  pressure,  as  from 
disease  of  the  vertebrse,  of  tumors,  connected  with  the  bones 
or  membranes,  encroaching  on  the  cord  and  setting  up  disease 
there,  or  of  injuries  to  the  cord ;  it  is  sometimes  met  with  in  the 
course  of  smallpox  and  of  low  fevers.  Compression  as  a  cause 
has  been  noted  in  the  cervical  as  well  as  in  the  other  portions  of 
the  spine.  Paralysis  of  the  arms,  with  dilated  or  contracted 
pupil  and  very  slow  pulse,  is  among  the  chief  symptoms  of  the 
"  cervical  paraplegia."  Pain  in  the  limbs,  hypersesthesia,  muscular 
contraction,  spasms,  and  great  reflex  irritability  are  among  the 
earlier  symptoms  of  this  as  of  all  tlie  other  forms  of  myelitis  from 


*  Hayem,  Archives  de  Physiologie,  Sept.  1874. 
f  Erb,  in  Ziemssen's  Cyclopaedia,  vol.  xiii. 


DISEASES    OF    THE    BRAIX    AND    SPIXAL    CORD.  119 

pressure;  but  as  the  case  progresses  the  reflex  irrituljility  is  lost. 
Yet  recovery,  almost  complete,  is  possible.* 

In  looking  at  the  symptoms  which  mark  the  extent  and  exact 
site  of  the  inflammation,  we  find  in  the  ordinary  form,  wliere  the 
disease  aifects  a  considerable  portion  of  tlie  thickness  of  the  cord, 
— the  transverse  myelitis, — with  the  ordinary  symptoms  of  com- 
plete paraplegia  and  ansesthesia,  that  the  reflex  excitability  is  pre- 
served or  increased,  and  that  the  muscles  respond  to  the  electric 
current.  This  is  not  the  case  in  central  myelitis,  which,  moreover, 
usually  runs  a  rapid  course,  in  which  there  is  speedy  loss  of  sen- 
sation and  of  reflex  action,  and  in  which  muscular  atrophy  soon 
shows  itself.  In  disseminated  myelitis  there  are  lulls  and  exacer- 
bations, the  paralysis  is  not  so  constant  nor  so  complete,  although 
it  may  be  in  all  four  limbs,  spastic  symptoms  are  not  uncommon, 
and  the  disease  develops  itself  after  acute  maladies,  as  after  'small- 
pox. Hemori^hagie  myelitis  is  usually  central ;  the  paraplegia 
comes  on  in  less  than  an  hour,  and  we  can  only  distinguish  it  from 
pure  hemorrhage  into  the  cord  if  fever  and  other  symptoms  of  an 
acute  myelitis  previously  existed.  In  children  the  anterior  cornua 
are  apt  to  be  affected,  and  the  disease  is  known  as  poliomyelitis. 

Softening  of  the  cord  cannot  with  any  certainty  be  distinguished 
from  myelitis  ;  the  inflammation  is,  in  truth,  the  usual  cause  of 
the  softening.  Of  atrophy  of  the  cord,  except  when  in  connection 
with  sclerosis,  we  have  no  trustworthy  knowledge. 

Spinal  Scleroses. — Now,  this  atrophy  of  the  nerve-substance, 
which  goes  hand  in  hand  wdth  the  increase  of  the  connective  tis- 
sue, may  be  found  in  any  part  of  the  cord,  may  show  itself  as 
a  uniform  alteration,  or  part  here,  part  there,  in  disseminated 
patches  of  disease.  Again,  we  may  have  the  same  alteration  in 
portions  of  the  brain,  or  the  lesion  may  be  limited  to  any  section 
of  the  cord.  The  sclerosis  where  brain  and  cord  both  suffer,  we 
shall  discuss  with  the  forms  of  tremor ;  posterior  sclerosis  of  the 
cord  gives  us  the  symptoms  of  locomotor  ataxia,  not  of  palsy. 
But  with  reference  to  sclerosis  of  the  antero-lateral  columns  some 
words  here  are  necessary.  It  usually  originates  without  known 
cause,  though  we  may  find  it  following  jars  and  blows  to  the  spine, 
or  well-marked  attacks  of  inflammation  of  the  cord.     It  may  be 

*  Buzzard,  Braiu,  April,  1880. 


120  MEDICAL    DIAGNOSIS. 

hereditary,  aud  is  pre-eminently  a  disease  of  middle  age,  lasting 
for  years,  showing  at  tinier  striking  ameliorations,  but,  exeept 
when  of  syphilitie  origin,  never  resulting  in  a  cure.  The  para- 
plegia which  it  induces  begins  rather  suddenly,  but  is  at  first  very 
incomplete;  certain  movements  alone  are  impossible;  the  feet  in 
walking  are  not  raised  high  enough  from  the  ground,  and  the 
patient  is  apt  to  stumble.  Reflex  movements  are  normal  or  in- 
creased ;  sensation  is  good,  and  so  is  at  first  the  electro-muscular 
contractility ;  pain  there  is  none,  unless  from  coexisting  spinal 
meningitis  ;  and  anaesthesia,  which,  when  present,  is  most  ajipareut 
in  the  soles  of  the  feet,  shows  that  the  malady  has  spread  to  the 
posterior  sections.  Indeed,  pure  cases  of  anterior  or  antero-lateral 
sclerosis  are  rare ;  the  sclerosed  patches  generally  become  dissemi- 
nated, and  we  find  the  heightened  reflexes  and  contractures  of 
the  expensively  developed  lesion  of  lateral  sclerosis  existing  to 
a  greater  or  less  degree,  or  the  disturbances  of  coordination  of 
locomotor  ataxia.  The  preponderance  of  the  symjjtoms  in  a  given 
case  of  disseminated  sclerosis  will  depend  upon  M'liere  the  patches 
in  the  cord  are  mostly  situated. 

Looked  at  from  a  diagnostic  point  of  view,  we  separate  pure 
anterior  or  antero-lateral  sclerosis  from  chronic  myelitis  by  the 
slower  beginning  but  more  rapid  course  of  the  latter,  by  the  much 
more  profound  palsy,  by  the  far  less  diminution  of  electro-mus- 
cular contractility  in  sclerosis,  and  by  the  comparative  absence 
of  bladder-afPection  which  this  shows.  From  congestion  of  the 
cord,  Avhich  also  may  begin  acutely,  antero-lateral  sclerosis  may  be 
diagnosticated  by  the  history  of  the  case,  the  varying  and  incom- 
plete palsy  in  the  former  malady,  its  being  influenced  by  the 
recumbent  posture,  the  pain  in  the  back,  the  sensation  of  numb- 
ness in  the  legs,  and  the  usual  and  early  ana?sthesia.  There  are 
puzzling  cases  for  diagnosis  between  some  forms  of  sclerosis  and 
tumors  of  the  brain  ;  but  the  choked  disks,  the  marked  headache, 
the  vertigo,  the  vomiting,  the  palsies  of  the  cerebral  nerves,  help 
us  to  distinguish  the  latter,  while  in  the  cerebro-spinal  variety 
of  sclerosis,  although  we  have  cerebral  symptoms,  we  find  the 
characteristic  tremor. 

Lateral  Sclerosis. — Primary  sclerosis  of  the  lateral  columns 
in  which  the  anterior  horns  are  not  affected  gives  the  group 
of  symptoms  described  as  spasmodic  dorsal  tabes  by  Charcot,  or 


DISEASES   OF   THE   BRAIN   AND   SPINAL   CORD.  121 

spastic  spinal  paralysis  by  Erb.  It  is  characterized  by  a  sensation 
of  weakness  in  the  back,  a  gradually  increasing  loss  of  muscular 
power  in  the  lower  extremities,  proceeding  slowly  from  below  up- 
wards, and  associated  with  reflex  spasms  and  persistent  muscular 
contractions,  with  increased  tendon  reflex,  but  without  impair- 
ment of  sensibility,  or  trophic  disturbances,  or  bedsores,  or  vesical 
disorder.  The  muscles  are  well  nourished,  or  only  very  slightly 
wasted ;  the  gait  is  very  peculiar,  the  walk  being  on  the  toes, 
and  as  the  foot  touches  the  ground  a  trembling  happens.  There 
are  no  cerebral  symptoms  whatever  ;  the  electrical  excitability  is 
either  normal  or  somewhat  lessened.  In  rare  instances  the  disease 
begins  in  the  upper  extremities ;  it  is  almost  always  of  very  slow 
development.  Occasionally  it  terminates  in  recovery.  It  is  most 
likely  that  the  disease  consists  essentially  in  a  primary  sclerosis 
of  the  pyramidal  tracts.  But  whether  the  group  of  symptoms 
may  not  be  produced  by  various  lesions  of  the  cord  is  not  settled. 
To  an  infantile  form  of  degeneration  of  the  lateral  columns 
McLane  Hamilton  has  called  attention.  Loss  of  power  in  the 
lower  extremities,  muscular  contractions  without  marked  atrophy 
or  greatly  impaired  electro-muscular  contractility,  such  as  happen 
in  infantile  paralysis,  increased  skin  and  tendon  reflexes,  and 
absence  of  sensory  disturbances  or  brain-symptoms,  are  the  chief 
signs  of  the  affection.* 

When  sclerosis  affects  the  lateral  columns,  and  is  combined  with 
degeneration  of  the  great  ganglion  cells  in  the  anterior  horns  of 
gray  matter  of  the  cord,  the  portion  which  has  a  controlling  influ- 
ence over  nutrition,  marked  nutritive  changes  happen  in  the  pal- 
sied part,  such  as  we  find  in  progressive  muscular  atrophy.  But 
the  lateral  amyotrophic  sclerosis,  as  Charcot  has  termed  it,  is  from 
the  onset  an  atrophy  of  a  whole  muscular  group.  It  is  a  disease 
which  lasts  only  a  few  years,  not  many  as  does  progressive  mus- 
cular atrophy,  afi^ects  as  a  rule  the  four  limbs  successively,  begin- 
ning in  the  arms,  produces  strange  deformities  in  the  wasted  and 
palsied  limbs,  which  are  often  agitated  by  fibrillar  movements, 
extends  to  the  hypoglossal  and  to  the  pneumogastric  nerves,  and 
thus  determines  death. 

Tumors  of  the  Cord. — Tumors  of  the  spinal  cord,  either 

*  Transactions  of  the  America-n  Medical  Association,  1879. 


122  MEDICAL    DIAGNOSIS. 

growing  from  it  or  its  membranes,  or  originating  in  the  vertebra? 
and  compressing  the  ncrve-struetnre,  occasion  paraplegia.  But  tlie 
cause  is  beyond  the  reach  of  positive  diagnosis.  We  suspect  tlio 
affection  if  we  have  emaciation  and  signs  of  a  grave  constitutional 
malady  attending  the  slowly  progressing  palsy,  if  this  be  more  de- 
cided on  one  side  than  on  the  other,  and  if  anesthesia  be  found  on 
the  side  opposite  to  that  in  which  the  palsy  is  marked  and  which 
is  the  seat  of  the  tumor.  Then  severe  pain  over  the  locality  of 
the  disease  occurs  in  cancerous  new  formations, — and  most  spinal 
tumors  are  cancerous, — and  is  aggravated  in  paroxysms.  The  pain 
is  generally  felt  on  one  side  first,  and  is  associated  with  tenderness 
of  the  spine  and  muscular  spasm.  This  is  especially  the  case 
when  the  growth  springs  from  the  membranes.  Yet,  unless  we 
have  distinct  evidence  of  tumors  elsewhere,  the  diagnosis  is  never 
more  than  an  uncertain  one.  If  multiple  tumors  exist,  it  may 
be  made  positive.  Strong  proofs  of  syphilitic  infection  point  to 
the  spinal  symptoms  being  due  to  a  syphilitic  growth  ;  and  signs 
of  scrofula,  or  tubercle  in  the  lungs  or  in  other  internal  organs, 
make  it  likely  that  similar  morbid  products  are  the  cause  of  the 
palsy.  Should  a  gradually  progressing  paralysis  suddenly  show 
symptoms  of  acute  myelitis  in  a  person  with  the  constitutional 
cachexia  just  mentioned,  we  have  an  additional  reason  for  sup- 
posing the  affection  to  be  tubercular  and  to  be  rapidly  extending.* 
Lymphadenomas  elsewhere  make  it  extremely  likely  that  the  spinal 
symptoms  are  due  to  one  or  several  of  them  in  the  cord.  Yet  the 
spinal  symptoms  in  the  affection  may  really  be  due  to  myelitis. 
In  all  cases  of  suspected  tumor  we  must  be  very  careful  that  bone- 
disease  is  not  the  cause  of  the  symptoms.  The  absence  of  sharp 
pain  and  the  uniformity  of  the  palsy  on  both  sides  are  strong 
points  of  distinction. 

Reflex  Paraplegia. — We  cannot  isolate  this  from  the  para- 
plegia of  organic  spinal  origin  with  any  certainty,  unless  we  can 
discern  the  source  of  the  irritation,  obtain  a  clear  history  of  the 
case,  and  satisfy  ourselves  of  the  absence  of  the  special  symptoms 
of  an  organic  disease  of  the  cord.  Some  distinctive  features  are, 
that  the  muscles  do  not  become  atrophied  ;  that  their  reflex  power 


*  See  cases  of  Hayem,  Archives  de  Physiologic,  1873 ;  and  Erb,  in  Ziems- 
sen's  Cyclopaedia. 


DISEASES   OF   THE    BKAIN    AND   SPINAI>   CORD,  123 

is  unimpaired ;  that  aiiEestliesia  is  exceptional ;  that  tlic  palsy  is 
seldom  complete  ;  that  some  muscles  ai^e  much  more  affected  than 
others ;  that  spasms  in  the  paralyzed  muscles  are  uncommon ; 
that  there  are  no  pains  in  the  spine,  produced  either  sijontaneously, 
or  by  pressure,  or  by  percussion,  or  by  applying  ice  or  a  hot  moist 
sponge ;  and  that  there  is  a  correspondence  between  changes  in 
the  degree  of  the  paralysis  and  changes  in  the  visceral  disease  or 
the  external  irritation  which  is  supposed  to  have  produced  the 
paraplegia.  But  it  is  certain  that  the  condition  of  inhibition  in 
affections  of  the  bladder  and  kidneys  and  other  states  which  is 
supposed  to  produce  the  reflex  paraplegia  is  very  infrequent.  A 
great  many  of  the  cases  are  really  due  to  an  ascending  neuritis. 

Worms  in  the  intestinal  canal  may  give  rise  to  reflex  para- 
plegia, which  disappears  with  their  expulsion.  A  form  of  reflex 
paralysis  produced  by  intestinal  disorder,  and  in  which  a  motor 
and  sensory  paraplegia  shows  itself,  has  been  carefully  studied  by 
Bartholow.* 

So  much  for  paraplegia.  We  shall  now  examine  some  of  the 
other  clinical  varieties  of  paralysis ;  beginning  with  a  group  in 
which  the  palsy  is  limited,  though  it  may  be  general. 

PALSIES   USUALLY  LIMITED,  THOUGH   THEY  MAY  BE    GEXERAL. 

Hysterical  Paralysis. — In  hysterical  paralysis  there  is  no 
structural  affection  of  the  brain,  yet  all  looks  as  if  this  were 
the  case.  This  form  of  paralysis  we  distinguish  from  that  of 
organic  disease,  by  its  occurrence  in  hysterical  persons ;  its  sud- 
den appearance,  and  frequently  its  just  as  sudden  disappearance  ; 
its  coming  on  generally  under  the  influence  of  some  powerful 
emotion,  often  after  an  attack  of  hysterical  convulsions ;  the 
absence  of  any  signs  of  a  serious  lesion  of  the  nervous  centres, 
except  the  paralysis ;  the  varying  nature  of  the  palsy,  sometimes 
hemiplegia,  sometimes  paraplegia ;  its  incomplete  character,  the 
patient  being  not  infrequently  able  to  move  while  under  strong 
excitement ;  and  the  ease  with  which  reflex  movements  are  brought 
on  in  the  seemingly  helpless  limb.  Moreover,  we  have  a  valua- 
ble test  in  electricity.     The  muscles,  except  in  cases  of  long  stand- 

*  See  Transact,  of  Phila.  College  of  Physicians,  Nov.  1883  ;  also  Barie, 
Arch.  Gen.  de  Med.,  IMov.  1881. 


124  MEDICAL    DIAGNOSIS. 

inii:,  contract  perfectly  under  its  stimulus,  both  under  the  faradaic 
and  the  galvanic  eurrent.  Duchenne  [)ointed  out  that  the  electro- 
muscular  sensibility  is  either  diminished  or  alxtlished,  \vhilc>  in 
cerebral  paralysis  it  is  intaet.  In  some  cases  ualvanie  sensibility 
is  lost.*  There  is  never  the  reaction  of  degeneration.  There  is 
hypersesthesia,  but  much  more  generally  ana?sthesia,  and  tiiis  also 
aifects  the  mnsiles.  But  museular  anaesthesia  may  be  absent  in 
hysteria.  Rapid  ehanges  occur  in  the  sensibility  nuder  strong 
electric  eurrents  or  under  metallo-therapy. 

Persons  affected  with  hysterical  palsy  are  striking  types  of  a 
nervous  constitution,  and,  as  Sir  James  Paget  f  mentions,  show 
a  singular  readiness  to  be  painfully  fatigued  by  slight  exertion. 
The  palsy  may  seize  only  upon  one  limb,  or  upon  part  of  one 
limb,  or  upon  special  muscles,  as  those  of  the  pharynx  and  ccsoph- 
agus,  the  larynx,  the  intestines,  and  the  diaphragm  ;  or  it  may, 
although  it  more  rarely  does,  assume  a  hemiplegic  or  a  paraplegic 
form.  Hysterical  hemiplegia  presents  a  peculiarity  in  the  gait, 
on  which  Todd  J  lays  great  stress.  ''In  walking,  when  the  palsy 
is  pretty  complete,  the  leg  is  dra^vn  along  as  if  lifeless,  sweeping 
the  ground.'"'  It  is  not  swung  round,  describing  the  arc  of  a 
circle,  as  it  is  in  ordinary  hemiplegia.  The  palsy  is  almost  in- 
variably left -sided.  It  is  apt  to  be  conjoined  to  very  decided 
ana?sthesia,  which  passes  beyond  the  paralyzed  part  to  the  nearest 
portion  of  skin  and  mucous  membrane,  though,  as  a  rule,  still 
limited  to  the  same  side.  Thus  we  find  the  pituitary  membrane 
of  one  nostril  rendered  insensible,  if  the  loss  of  feeling  affect  the 
face.  In  hysterical  paraplegia  we  find  the  same  incompleteness  of 
the  palsy  and  the  same  response  to  electric  tests  already  nicntioned, 
and  we  are  also  very  apt  to  have  the  symptoms  of  spinal  irrita- 
tion. Hysterical  contractions  of  the  muscles  especially  affect  the 
lower  extremity.  These  hysterical  contractures,  as  they  are  now 
usually  called,  generally  come  on  quickly,  appear  to  be  permanent, 
and  to  be  associated  with  palsy  of  one  or  both  legs,  but  disappear 
as  suddenly  as  they  showed  themselves.     Yet  they  may  really 

*  Wood,  Nervous  Diseases  and  their  Diagnosis,  1887. 

f  Xervous  Mimicry  of  Organic  Diseases,  in  Clinical  Lectures  and  Essays, 
London,  1875. 

X  Clinical  Lectures  on  Paralysis  and  other  Aflections  of  the  Nervous  Sj'S- 
tem,  Lecture  XIII. 


DI§EASj:S    OF   THE    BRAIX    AND    SPINAL    CORD.  125 

become  permanent  and  c(jmbined  with  sclerosis  of  the  cord,  and 
we  may  find  them  associated  with  tremor,  and  with  exaggerated 
knee-jerk.  Ankle  clonus  has  also  been  observed  Ijy  Charcot  as 
occurring  in  hysterical  paralysis.  Gowers,  however,  thinks  that 
true  uniformly  persisting  ankle  clonus  bespeaks  secondary  organic 
disease  in  the  motor  parts  of  the  cord,  while  a  spurious  irregular 
clonus,  now  ceasing,  now  renewed  by  a  fresh  contraction  of  the 
muscle,  is  characteristic  of  hysteria. 

Rheumatic  Paralysis, — Eheumatic  paralysis  resembles  hys- 
terical paralysis  in  being  ordinarily  limited.  It  may  affect  any 
muscle  or  any  group  of  muscles  in  the  body ;  sometimes  the  rheu- 
matic poison  disorders  the  portio  dura,  and  we  observe,  in  con- 
sequence, facial  palsy ;  or  it  may  fasten  on  the  radial  nerve,  and 
we  have  groups  of  muscles  in  the  forearm  palsied.  Eheumatic 
paralysis  is  recognized  by  the  history  of  the  case  ;  by  the  evi- 
dences of  a  rheumatic  attack ;  by  the  rapid  development  of  the 
palsv ;  by  the  pain  which  usually  attends  it ;  and  by  its  being 
unaccompanied  by  symptoms  strictly  referable  to  a  disease  of  the 
nerve-centres.  It  may  or  may  not  be  attended  by  anaesthesia. 
The  muscles  themselves,  certainly  in  those  cases  in  which  they, 
rather  than  a  large  nervous  branch,  are  primarily  and  chiefly 
affected,  are  readily  acted  upon  by  electricity,  unless  their  struc- 
ture be  altered ;  and  the  electro-muscular  sensibility,  though  it 
may  be  lessened,  is  not  abolished. 

Lead  Palsy. — Paralysis  from  lead  poisoning  occurs  primarily, 
and  sometimes  only,  in  the  extensor  muscles  of  the  arm,  occa- 
sioning the  well-known  wrist-drop.  It  generally  begins  in  the 
extensor  communis,  then  affects  the  radial  and  ulnar  extensors. 
Gradually  other  muscles  become  involved  :  there  is  loss  of  power 
in  the  ball  of  the  thuml^,  in  the  deltoid,  and  in  the  triceps,  but 
not  in  the  supinator  longus,  or  in  the  intercostal  mtiscles,  or  in 
those  of  the  lower  extremities.  The  disturbed  muscles  on  both 
sides  of  the  body  waste,  entirely  lose  their  irritability  to  electricity, 
and  soon  show  the  reaction  of  degeneration.  The  patient  is  weak  : 
his  movements  are  tremulous ;  he  has  the  characteristic  blue  line 
on  the  gums,  is  obstinately  constipated,  is  subject  to  colic,  and 
lead  can  be  found  in  the  urine.  Sometimes  the  poison  seizes  upon 
the  brain,  and  epileptic  convulsions  and  other  signs  of  a  serious 
cerebral   affection   appear,  and  we   find  marked  optic  neuritis. 


126  MEDICAL    DIAGNOSIS. 

From  the  locality  of  the  ]xilsy,  in  addition  to  the  accompanying 
symptorps  and  the  knowledge  of  the  man's  employment,  the  diag- 
nosis is  usually  arri\-ed  at  \vitli  ease.  Paralysis  produced  by  an 
affection  of  the  radial  nerve  shows  the  greatest  similarity.  But 
here  the  supinator  muscles  as  well  as  the  extensors  are  affected, 
which  is  not  the  case  in  lead  paralysis,  where  the  patient  can  carry 
the  liand  supine. 

Diphtheritic  Paralysis. — Diphtheritic  paralysis  is  a  sequel 
of  diphtheria  which  follows  an  attack  of  that  disease  within  a 
fortnight  or  two  months,  and,  therefore,  after  the  patient  is  to  all 
appearance  fully  convalescent.  It  may  be  very  localized,  merely 
affecting  the  palate  or  the  pharynx  ;  or  very  general,  fastening 
upon  both  of  the  lower  extremities,  and  even  ujxju  the  upper. 
When  extensive,  it  is  always  ushered  in  by  a  change  in  the  voice 
and  a  throat-palsy ;  there  is  difficulty  in  swalloM'ing,  and  the 
saliva  dribbles  from  the  mouth.  The  eye-muscles  are  apt  to  be 
disturbed,  and  paralysis  of  accommodation  and  strabismus  and 
double  vision  are  not  uncommon.  The  paralysis  of  the  ex- 
tremities ensues  gradually ;  day  by  day  the  muscular  po^^■er  is 
more  and  more  enfeebled.  The  loss  of  motion  is  oflen  preceded 
by  formication,  and  attended  by  a  certain  amount  of  anaesthesia. 
The  faradaic  electro-muscular  contractility  and  sensibility  are  di- 
minished, and  the  galvanic  current  shows  mostly  the  same  results. 
The  palsy  mends  as  slowly  as  it  comes  on ;  yet  most  cases  fully 
recover.  The  brain  itself  is  not  affected ;  at  least  there  were  no 
symptoms  of  cerebral  mischief  in  the  cases  which  have  come  under 
my  observation.  The  cause  of  the  paralysis  is  ol)Scure.  By  many 
it  is  looked  upon  as  a  peripheral  palsy  due  to  multiple  neuritis. 

Syphilitic  Paralysis. — Paralysis  from  syphilis  we  find  in 
persons  presenting  signs  of  constitutional  syphilis,  and  in  whom 
any  serious  nervous  disturbance  points  to  a  local  manifestation 
of  syphilis  in  the  nervous  centres.  jSTot  unusually  the  syphilitic 
exudation  is  localized  in  the  course  of  one  or  of  several  nerves, 
and  we  have,  for  instance,  paralysis  of  the  sixth  or  paralysis  of 
the  fifth  with  or  without  paralysis  of  some  other  cerebral  nerve. 
But  as  syphilis  attacking  the  nervous  system  is  chiefly  character- 
ized by  a  want  of  uniformity  in  the  lesions  it  ]iroduces,  so  we 
observe  dissimilar  phenomena  preceding  or  attending  the  palsies. 
Thus,  we  may  or  may  not,  though  in  point  of  fact  we  usually 


DISEASES    OF   THE    BRAIN    AND    SPINAL    CORD.  127 

do,  find  the  paralysis  associated  with  pain  in  the  head,  with  optic 
neuritis,  with  sleeplessness,  vertigo,  impaired  memory,  and  sick- 
ness at  the  stomach.  Decided  vertigo  is  prone  to  take  place 
where  the  syphilitic  affection,  as  it  so  often  does,  lias  led  to 
disease  of  the  vessels,  and  is  apt  to  be  the  forerunner  of  hjcal 
softenings  and  of  hemiplegia.  When  disease  of  the  membranes 
has  happened,  headache  is  generally  severe,  and  local  spasms  or 
convulsions  occur.  The  same  symptoms  are  encountered  when 
there  is  a  growth  in  the  hemisphere,  which  is  very  apt  to  be  near 
the  surface  of  the  brain ;  though  here  again  the  form  of  mischief 
may  be  comparatively  latent,  the  patient  may  have  only  occasion- 
ally convulsions,  and  the  paralysis  be  slight  or  improving,  yet  a 
fatal  coma  may  follow  a  few  convulsions.  Instances  of  this  have 
come  under  my  observation. 

But,  as  a  rule,  syphilitic  paralysis  does  not  terminate  fatally. 
In  truth,  the  ease  with  which  the  palsy  and  its  attending  phe- 
nomena yield  to  treatment,  if  we  except  marked  instances  of  hard 
nodules,  forms  one  of  the  traits  of  the  malady.  Other  common 
features,  to  speak  in  general  terms  and  taking  into  account  what 
has  been  said  of  the  dissimilar  character  of  the  lesions,  are — that 
it  ordinarily  affects  persons  younger  than  those  in  whom  we  find 
paralysis  dependent  upon  disease  of  the  nervous  centres,  and  espe- 
cially of  the  brain ;  and  that  its  manifestations  are  shifting  and 
capricious,  and  rarely  symmetrical.  These  same  traits  charac- 
terize syphilitic  affections  of  the  nervous  system  in  Avhich  paral- 
ysis is  not  among  the  symptoms.  Paralysis  of  the  third  nerve  is  a 
frequent  result  of  syphilis  ;  *  but,  as  already  stated,  the  poison  may 
attack  any  part  of  the  nervous  system,  and  paraplegia  dependent 
upon  disease  of  the  cord  is  not  very  uncommon.  A  progressive 
multiple  palsy  of  cerebral  origin,  clearly  affecting  dissociated 
muscles,  is  usually  syphilitic,  and  is  mostly  due  to  several  patches 
of  gummatous  meningitis.  At  times  a  rapid,  almost  universal 
paralysis,  as  Buzzard  notices,  occurs  in  syphilitic  subjects.  This 
is  very  likely  of  peripheral  origin.  It  is  among  the  peculiar 
traits  in  syphilitic  palsy  that  the  lost  electro-muscular  contractility 
returns  rapidly,  f 


*  Broadbeiit,  Lancet,  Jan.  1874. 

t  Engel,  Phila.  Med.  Times,  Dec.  1877. 


1'2S  MEDICAL   DIAGNOSIS. 

The  mischief  to  the  nervous  system  may  not  hni)pen  for  ycare 
after  the  infection.  It  may  be  the  result  of  an  inherited  taint.  But 
such  cases  cannot  he  recognized  unless  there  are  other  signs  of 
syphilis  than  the  suspected  nervous  symptoms;  and  chief  among 
these  signs  are  the  evidences  of  periostitis  in  the  long  bones  and  of 
disseminated  choroiditis  in  the  fundus  of  the  eye.  Then  there  is 
that  valuable  test  of  congenital  syphilis  discovered  by  Mr.  Hut- 
chinson,— a  malformation  of  the  two  upper  central  jiermanent 
incisors,  which  consists  in  their  being  narrower  at  their  cutting- 
edges  tiiau  at  their  insertions,  and  often  notclied.  The  same  ob- 
server has  called  attention  to  diffused  opacity  of  the  cornea  and 
to  diseased  nails  as  being  common  among  tlie  manifestations  of 
the  inherited  disease.  Paralysis  also  may  occur,  as  in  the  case 
reported  by  Bartlett ;  *  but  it  is  very  rare. 

LOCAL    PALSIES. 

The  forms  of  paralysis  which  have  just  been  noticed  are  mainly 
such  as  are  designated  as  partial.  AVhen  the  loss  of  power  is 
very  limited,  the  palsy  is  spoken  of  as  local ;  most  of  these  local 
palsies  are  peripheral. 

Facial  Palsy. — Of  the  local  paralyses,  of  particular  im- 
portance— from  its  frequency — is  facial,  or  Bell's  palsy.  The 
disease  consists  in  an  affection  of  the  portio  dura  of  the  seventh 
nerve.  In  consequence  of  the  derangement  of  this  motor  nerve, 
nearly  all  the  muscles  of  the  face  lose  their  faculty  of  motion, 
and,  as  it  is  their  play  which  gives  expression  to  the  counte- 
nance, the  appearance  of  the  face  is  extraordinary.  The  eye- 
lids are  open  and  fixed ;  the  features  are  rigidly  composed  on 
one  side  of  the  face,  but  reflect  every  change  of  feeling  on  the 
other ;  and  in  the  old  the  furrows  disappear  from  the  forehead, 
and  the  eye  waters.  In  some  cases  the  velum  palati  is  involved 
in  the  paralysis.  Sensation  remains  unimpaired  as  long  as  the 
fifth  nerve  is  not  disturbed. 

The  causes  of  the  palsy  are  such  as  influence  the  distressed 
nerve  in  its  course  or  at  its  periphery  :  a  wound  ;  mumps ;  ear- 
disease  ;  exposure  to  cold  ;  rheumatism.  The  most  common  cause 
is  a  neuritis  from  cold  affecting  the  nerve  within  the  Fallopian 

*  Clinical  Society's  Transactions,  vol.  iii. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  129 

canal.  The  malady  is  easily  cliscriminatod  from  tlic  facial  palsy 
of  disease  of  the  brain  by  the  inability  to  close  tlic  eyelids,  owing 
to  tlie  paralysis  of  the  orbicnlaris  palpebrarum ;  by  the  absence 
of  headache,  of  vertigo,  of  mental  confusion,  of  loss  of  memory  ; 
by  the  much  more  complete  though  strictly  local  character  of  the 
paralysis ;  and,  except  in  slight  lesions  of  the  nerve,  by  the  lost 
eleetro-mnscLilar  contractility.  In  severe  cases,  indeed,  the  muscles 
soon  cease  to  respond  to  faradization,  while  the  galvanic  irritability 
is  preserved  and  even  heightened,  and  the  reaction  of  degenera- 
tion is  very  marked.  Electric  stimulation  of  the  diseased  nerve 
shows  that  it  quickly  loses  its  excitability  both  to  the  faradaic  and 
the  galvanic  current. 

Recent  observations,  especially  those  of  Erb,  enable  us  to  tell 
Avith  considerable  accuracy  the  exact  part  of  the  nerve  affected. 
They  take  into  account  well-known  anatomical  and  physiological 
facts,  and  lead  to  these  conclusions.  If  there  be  complete  palsy 
of  all  the  facial  branches  with  the  exception  of  the  posterior  au- 
ricular nerve,  the  lesion  is  in  the  main  trunk  of  the  facial,  exterior 
to  the  Fallopian  canal.  If  the  auricular  nerve  be  also  implicated, 
the  lesion  is  within  the  Fallopian  canal  below  the  origin  of  the 
chorda  tympani,  the  most  common  seat  of  the  affection.  If  taste 
and  salivary  secretion  be  disturbed  on  the  side  of  the  tongue  corre- 
sponding to  the  palsy  of  the  face-muscles,  the  lesion  is  between  the 
points  where  the  chorda  tympani  and  the  tympanic  branch  are  given 
off.  If  in  addition  the  seUvSe  of  hearing  be  abnormally  increased, 
we  may  infer  that  the  nerve  is  affected  between  the  tympanic 
branch  and  the  geniculate  ganglion,  and  at  the  latter  point  palsy 
of  the  palate  is  superadded  ;  and  higher,  up  to  the  entrance  into 
the  brain,  disorders  of  taste  happen.  Eventually  implication  of 
other  cranial  nerves,  as  of  the  auditory,  also  occurs. 

Cases  of  facial -nerve  palsy  generally  recover.  Sometimes,  how- 
ever, the  recovery  is  incomplete,  and  a  rigidity  with  some  con- 
traction of  the  affected  muscles  takes  place,  which,  when  slight, 
may  make  the  sound  side  appear  relaxed,  and  the  diseased  side 
seem  the  normal  one. 

In  rare  instances  the  facial  palsy  is  on  both  sides.  IS^ow,  in 
this  double  facial  palsy  the  lesion  may  be  within  the  cranium, 
such  as  compression  by  a  tumor,  or  may  affect  the  nerves  while 
passing  through  the  medulla  and  pons  in  their  farther  course. 


130  :\rEDiCAL  diagnosis. 

^yheu  dependent  sim])ly  (in  a'loeal  atfection,  and  therefore  limited 
to  the  ananifestations  of  paralysis  of  the  portio  dura,  Ave  find  the 
same  causes  at  work  which  give  rise  to  the  one-sided  disease. 
Exposure  to  cold  and  rheumatism  are  the  most  frequent ;  but 
syphilis  is  also  among  the  causing  elements.  In  an  instance  de- 
tailed by  Todd  in  his  clinical  lectures,  in  which  there  was  disease 
of  tiie  temporal  bone,  the  portio  mollis  was  also  implicated.  The 
face  is  immovable,  or  nearly  so,  and  the  palsy  is  generally  more 
complete  on  the  left  side  than  on  the  right.  The  muscles  do  not 
respond  to  electricity,  or  respond  imperfectly,  and  we  notice,  as 
in  the  one-sided  malady,  that  a  continuous  current  may  excite 
their  action,  while  faradization  does  not.  Nay,  the  two  sides  may 
give  different  results  in  this  respect, "*'  most  likely  caused  by  diifer- 
ent  conditions  of  exudation  and  of  pressure  on  the  affected  nerves. 

Paralysis  of  the  Nerves  of  the  Arm. — Paralysis  of  one 
or  more  nerves  of  the  arm  is  very  often  encountered.  It  may 
happen  from  rheumatism,  from  cold  developing  a  neuritis,  or  from 
the  pressure  of  a  growth  ;  but  its  most  common  cause  is  accidental 
compression.  A  person  falls  asleep  with  his  head  on  his  arm, 
and  a  temporary  palsy  results.  In  truth,  the  disorder  may  be 
taken  as  the  type  of  the  palsies  by  compression,  and  we  find  here, 
therefore,  the  rule,  Avhich  is  thought  to  be  invariable  in  this  class 
of  palsies,t  that  the  electro-muscular  contractility,  even  A\hen 
the  loss  of  voluntary  motion  is  complete,  is  preserved,  or  only 
diminished,  not  abolished. 

The  nerve  most  frequently  paralyzed  is  the  musculo-spiral,  or 
its  main  branch  the  radial,  and  we  observe  palsy  of  the  extensors 
of  the  wrist  and  the  fingers  and  of  the  supinators.  In  the  loss  of 
power  in  these  muscles,  and  in  the  slightly  altered  electric  irrita- 
bility, we  find  the  differences  between  the  palsy  under  considera- 
tion and  the  wrist-drop  of  lead  palsy.  From  those  diseases  of 
the  spinal  cord  which  begin  Avith  arm  palsy,  the  local  malady  is 
distinguished  by  the  tenderness  in  the  course  of  the  nerve,  and 

*  Case  of  Baerwink'el,  Schmidt's  Jahrb.,  Bd.  cxxxvi.  No.  1.  For  other 
cases  of  double  facial  palsy,  see  Gairdner,  Lancet,  May  18,  1861 ;  Pellet,  Tra- 
vaux  de  la  Societe  Medicale,  1867;  Wright,  British  Medical  Journal,  Feb. 
1869. 

f  Chapoy,  quoted  in  Arch.  Gen.  de  Med.,  Sept.  1874.  See  also  cases  of 
radial  paraly.sis,  by  Panas,  lb.,  June,  1873, 


DISEASES    OF    THE    BRAIN    AND   SPINAL    CORD.  L'il 

the  one-sidecl  paralysis.  The  same  separates  this  arm  ])alsy  from 
the  loss  of  power  in  the  •  wrists,  arising  from  atrophy  of  the 
muscles  in-  the  overworked  parts,  occurring  in  jiersons  whose 
stomachs  do  not  take  in  a  sufficient  supply  of  nutriment,  as  in 
poorly-fed  and  hard- worked  shoemakers.* 

About  other  local  palsies,  as  of  the  pharynx  and  oesophagus,  of 
the  larynx,  of  one  side  of  the  palate,  of  the  tongue,  of  the  mus- 
cles of  the  eye,  of  the  diaphragm,  of  isolated  muscles  of  the  trunk, 
and  of  the  extremities,  it  is  impossible  here  to  enter  into  particu- 
lars. But  there  are  some  forms  of  local  palsy  which,  from  their 
striking  interest,  it  is  necessary  to  describe,  the  most  important 
of  which  is  the  paralysis  of  the  tongue  and  parts  concerned  in 
deglutition. 

Bulbar  Paralysis. — In  this  bulbar  or  glosso-labio-laryngeal 
paralysis,  the  first  symptoms  which  are  likely  to  attract  attention 
are,  that  the  tongue  seems  less  supple  and  the  utterance  becomes 
nasal  or  thick,  the  food  lodges  between  the  teeth  and  cheek,  and 
the  saliva  dribbles  from  the  lips  and  corners  of  the  mouth.  As 
the  paralysis  progresses,  articulate  speech  is  almost  lost,  as  is  the 
reflex  action  in  the  throat ;  the  shape  of  the  tongue  is  altered,  it 
generally  dwindles,  and  at  times  shows  twitching  of  its  fibres,  or 
lies  motionless  in  the  mouth,  though  it  reacts  to  faradization ;  the 
posterior  nares  can  no  longer  be  closed  by  the  velum  and  muscles 
of  the  posterior  palatine  arch  ;  deglutition  becomes  very  difficult, 
and  the  patient  is  tormented  with  hunger.  The  mucous  mem- 
brane of  the  larynx  is  frequently  insensible ;  the  respiratory  move- 
ments are  unusually  weak,  and  fits  of  suffocation  ensue.  The 
general  debility  becomes  extreme,  and  the  patient  is  apt  to  perish 
by  the  sudden  stoppage  of  the  heart's  action.  The  disease  is  un- 
mistakable. Double  facial  palsy  resembles  it  most ;  but  here  the 
tongue  is  not  involved,  and  the  eyelids  remain  open  ;  on  the  other 
hand,  in  bulbar  paralysis  the  lower  part  of  the  face  onlv  is  mo- 
tionless. This  malady  may  have  an  acute  beginning,  and  seem- 
ingly in  cold  ;  it  is  sometimes  complicated  with  weakness  of  the 
muscles  of  one  side  of  the  body,  or  with  muscular  atrophy  in 
the  limbs  and  trunk.  As  a  rale,  the  mind  remains  clear.  The 
affection  is  generally  of  rather  slow  development  and  slow  but 

*  Chambers  on  the  Indis;estions. 


132  MEDICAL    DIAGNOSIS. 

relentless  progress;  but  it  is  not  nearly  so  chronie  a  malady  as 
progressive  muscular  atropliy,  which  may  last  from  ten  to  twenty 
years,  Avhile  the  bulbar  paralysis  has,  like  lateral  sclerosis,  an 
average  duration  of  from  one  to  three  years.*  Progressive  bul- 
bar paralysis  has  its  seat  of  lesion  in  the  medulla  oblongata,  in 
the  motor  nuclei,  which  undergo  a  degenerative  atrophy  ;  and  we 
understand  the  main  symptoms  when  we  reflect  on  tlie  nuclei 
which  connect  the  liypoglossal,  the  spinal  accessory,  the  vagus, 
and  the  facial. 

With  reference  to  all  these  local  palsies  we  are  sometimes  nnich 
perplexed  to  know  if  the  j)alsy  be  the  result  of  beginning  disease 
of  the  brain  or  spinal  cord,  or  if  it  be  ])urely  local.  To  speak 
first  of  the  brain  :  the  cerebral  symptoms  may  not  be  marked,  or 
they  may  be  so  contradictory  as  to  afford  no  real  help  in  diagno- 
sis. AVhen,  however,  we  discover,  as  we  generally  can,  that  the 
palsy  affects  muscles  which  are  supplied  by  different  nerves  and 
such  as  hav^e  no  communication  Avith  one  another,  we  may  set 
down  the  complaint  as  having  a  central  origin.  As  regards  the 
distinction  from  spinal  affections,  the  single-sided  character  of 
the  symptoms  in  local  palsies,  excepting  bulbar  paralysis,  and 
their  doublc-sidcd  nature  in  spinal  affections,  are  very  important. 

PALSIES    COXXECTED    AVITH    IMARKED    MUSCULAR    WASTING. 

There  is  a  group  of  palsies  especially  marked  by  wasting  of 
the  muscles.  In  some  affections  already  discussed  we  have  found 
wasting  among  the  symptoms,  as  at  times  in  myelitis,  and  in 
cervical  pachymeningitis  Avith  considerable  damage  to  the  nerv^e- 
roots,  AA^here  atrophy  of  the  arms  happens.  Again,  atrophy  of 
the  muscles  of  the  trunk  and  limbs  is  often  met  with  in  the 
advanced  stages  of  progressive  bulbar  paralysis.  But  in  all 
these  affections  there  are  other  and  more  distinctive  symptoms. 
In  some  affections  the  wasting  of  the  muscles  is  the  pre-eminent 
feature.  This  is  particularly  the  case  in  progressive  muscular 
atrophy  and  in  the  essential  paralysis  of  childhood. 

Another  important  cpiestion  Avhich  may  arise — and  with  refer- 
ence not  only  to  limited  but  also  to  extended  palsies — is,  Avhether 
the  loss  of  muscular  power  be  not  in   reality  dependent  upon 

*  Mobius,  Schmidt's  Jahrb.,  No.  2,  1882. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  133 

changes  in  the  muscular  tissue,  and  especially  upon  that  change 
found  in  the  disorder  known  as  progressive  muscular  atrophy. 

Progressive  Muscular  Atrophy. — Concerning  the  nature 
of  this  ''  wasting  palsy"  we  are  as  yet  in  doubt.  We  find  in  it, 
as  pointed  out  by  Aran,  atrophy  connected  with  fatty  transfor- 
mation of  the  muscular  fibres ;  yet  whether  due  primarily  to 
changes  of  these  structures  or  dependent  on  alterations  in  the 
peripheral  nerves,  as  affirmed  in  the  elaborate  treatise  of  Fried- 
reich,* is  uncertain.  But  since  the  observations  of  Charcot,  the 
weight  of  opinion  is  strongly  in  favor  of  a  central  origin, — of 
degenerative  changes  in  the  gray  substance  of  the  cord,  particu- 
larly in  the  large  ganglion  cells  of  the  anterior  horns,  in  the  motor 
fibres  coming  from  them,  and  in  the  pyramidal  tracts  giving  rise 
to  the  lesion  that  determines  the  muscular  atrophy. 

Progressive  muscular  atrophy  is  a  disease  of  adults,  and  essen- 
tially of  men.  Its  most  striking  sign  is  increasing  inability  to 
perform  certain  movements.  When  the  muscle'chiefly  concerned 
in  the  attempted  motion  is  examined,  it  is  found  to  have  dwindled. 
Soon  other  muscles  follow  ;  and  their  wasting,  too,  is  accompanied 
by  further  muscular  weakness.  Portions  of  the  disorganizing 
muscles  twitch,  much  to  the  annoyance  of  the  patient,  and  tap- 
ping them  sharply  causes  a  marked  contraction  of  the  fibres.  In 
the  affected  part  the  circulation  becomes  languid  ;  it  is  also  very 
susceptible  to  cold,  and  indeed  its  temjaerature  is  lowered  ;  there 
is  a  feeling  of  numbness  in  it,  but,  as  the  disease  progresses,  rarely 
pain  ;  to  pressure  it  is  soft  and  yielding.  The  muscles  most  fre- 
quently attacked  are  those  of  the  hand ;  the  flexors  and  supina- 
tors of  the  forearm ;  the  biceps,  the  deltoid,  and  the  other  mus- 
cles of  the  shoulder.  Sometimes  the  disease  begins  in  the  trunk 
and  the  lower  extremities  ;  but  it  is  most  couimon  to  have  it 
marked  in  the  upper  extremities  and  to  find  only  weakness  and 
spasm  in  the  lower.  The  decrease  of  the  muscular  fibres  gives 
rise  to  strange  and  palpable  deformities,  and,  when  the  muscles 
of  the  trunk  are  involved,  to  extraordinary  positions  of  the  body, 
in  consequence  of  all  antagonism  to  the  healthy  muscles  having 
been  removed. 

In  the  parts  affected  the  reflex  action  is  lost ;  even  the  defep 

*  Progressive  Muskelatrophie,  etc.,  Berlin,  1874. 


134  MEDICAL    DIAGNOSIS. 

reflexes  disappear.  \\e  see  this  lia])pening  with  the  l^nee-jeik 
jiist  as  soon  as  the  muscles  of  the  legs  become  flaccid  and  begin 
to  Avaste.  To  the  electric  currents,  both  faradaic  and  galvanic, 
the  muscles  respond  feebly  ;  still  they  resjiond,  and  in  i)()rtions 
■where  there  are  many  sound  fibres  they  contract  energeticalh . 
The  degree  of  response  depends,  indeed,  on  tlie  degree  of  disor- 
panization  and  wastino-.  The  excitability  to  the  jialvanic  current 
is  ai)t  to  remain  much  longer  than  that  to  faradization. 

^^'Ilen  we  contrast  progressive  muscular  ati-ophy  with  the  forms 
of  paralysis  with  which  it  may  be  confounded,  we  find  several 
features  at  variance.  From  cerebral  hemiplegia  it  differs  by  its 
much  more  gradual  invasion,  by  the  rapidity  but  want  of  uni- 
formity with  which  the  muscular  atrophy  takes  place,  by  tlie  lost 
reflexes,  by  the  diminished  electric  excitability,  and  by  the  ab- 
sence of  disordered  intellect  and  of  other  signs  of  disease  of  the 
brain.  Difiiculty  in  articulation  and  in  deglutition  may  occur  in 
either.  From  general  spinal  j^ara^^.s/s  it  is  diagnosticated  by  the 
spinal  malady  affecting  primarily  all  the  muscles  of  the  lower 
extremities  before  those  of  the  upper  become  involved.  Then, 
too,  if  the  spinal  paralysis  be  due,  as  it  so  generally  is  when  ex- 
tensive, to  myelitis,  the  alterations  of  sensibility,  the  totally  lost 
electro-muscular  contractility,  and  the  affection  of  the  sphincters 
are  striking  traits  of  difference.  Another  Avay  of  discriminating 
between  the  muscular  atrophy  and  the  diseases  just  considered,  is 
by  the  means  of  instruments  by  which  portions  of  the  affected 
textures  can  be  removed  and  subjected  to  microscopical  examina- 
tion. Duchenne  invented  a  trocar  for  the  purjjose ;  I  think  the 
best  is  that  of  Hart.* 

The  difficulty  of  distinguishing  cases  of  local  jmralysis  from 
progressive  muscular  atrophy  is  at  times  very  great.  Yet  gen- 
erally we  may  separate  the  latter,  for  instance  from  rheumatic 
palsy,  by  noticing  that  this  affects  a  group  of  muscles  rather  tlian 
one  muscle,  or  than  one  muscle  here  and  another  there.  Further, 
the  atrophied  muscle  in  the  rheumatic  disorder  is  the  seat  of  j)ain 
intensified  by  movement,  and  it  contracts  well  under  the  electric 
stimulus.  The  same  test  by  the  electric  current  is  of  service  in 
discriminating  the  muscular  disease  from  hysterical  paralysis,  and 

*  Medical  ]Srews  and  Abstract,  March,  1881. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  1-35 

from  paralysis  consequent  upon  injuries  to  nerve  trunks  and 
upon  lead  poisoning.  In  the  first  of  these  palsies  the  electrical 
contractility  is,  except  temporarily  in  cases  of  old  standing,  intact, 
in  the  others  it  is  abolished  ;  while  in  progressive  muscular  atrophy, 
save  when  the  wasting  is  extreme,  it  is  simply  enfeebled.  Jiesides 
this  test,  the  unimpaired  sensibility,  the  capricious  and  unequal 
manner  in  which  the  atrophy  seizes  upon  the  muscles  in  this 
maladv,  the  fibrillation,  and  the  beffinnins:;  of  the  wastino;  in  the 
thenar  muscles  and  tlie  interossei  are  points  to  which  we  attach 
importance. 

The  most  difficult  differential  diagnosis  we  may  be  called  upon 
to  make  is  to  distinguisli  certain  cases  of  progressive  muscular 
atrophy  from  bulbar  paixdysis.  In  truth,  the  two  affections  often 
coexist,  and  the  features  of  each  may  be  blurred  to  the  last  degree. 
In  acute  cases  we  are  helped  by  the  more  rapid  development  of 
the  paralysis  in  the  latter  malady,  sometimes  occurring  as  it  does 
in  a  few  days,  and  without  at  first  that  proportional  reduction  in 
the  size  and  strength  of  the  muscle  which  we  find  in  progressive 
muscular  atrophy.  In  chronic  cases  the  diagnosis  may  be  at  first 
very  difficult  should  the  progressive  muscular  atrophy  be  limited, 
all  the  more  difficult  because  electro-muscular  contractility  and 
sensation  may  be  in  both  but  little  affected.  Defective  pronun- 
ciation points  to  the  bulbar  malady.  Failure  of  the  respiratory 
power  is  common  to  both. 

Local  atrophies  may  be  mistaken  for  part  of  the  general  disease. 
There  is,  for  instance,  an  affection,  unilateral  progressive  atrophy 
of  the  face,  in  which  gradual  wasting  of  one  side  of  the  face 
occurs,  of  the  soft  parts  first,  and  then  of  the  deeper  tissues.  It 
begins  with  a  discoloration  of  circumscribed  spots,  a  white  or 
yellowish  discoloration,  the  subcutaneous  fat  disappears,  and  the 
beard  and  eyelashes  change.  Sensation  is,  as  a  rule,  not  affected, 
nor  are  the  electrical  reactions  changed.*  But  in  progressive 
muscular  atrophy  the  face  almost  always  escapes ;  if  it  be  affected 
it  is  so  on  both  sides.  Another  limited  atrophy  is  a  muscular 
wasting  from  overuse  of  muscles,  especially  seen  in  the  small  mus- 
cles of  the  hand.     It  shows  no  tendency  to  extend. 


*  See  cases,  Journal  of  Nervous  and  Mental  Diseases,  ~New  York,  March, 
1880;  Schmidt's  Jahrb.,  No.  7,  1881 ;  and  St.  Louis  Alienist,  April,  1881. 


136  MEDICAL    DIAGNOSIS. 

Paralyzed  muscles  atrophy,  and  may  subsequently  undergo  a 
fatty  change.  To  distinguish  such  a  condition  from  progres- 
sive muscidar  atroj^hy  is  not  easy.  We  have  to  lay  stress  on 
the  symptoms  which  ushered  in  the  paralytic  state,  and  which 
attend  it. 

In  that  rare  affection  synngo-myelitis,  in  which  the  central  gray 
column  becomes  changed  into  a  mass  of  connective  tissue  and  the 
interior  st)ftcns,  Ibrming  a  cavity,  we  have  fibrillar  contractions 
in  the  alfccted  muscles  and  atrophy  with  resulting  deformities. 
There  is  no  pain,  and  sensation  is  not  dist)rdered,  though  auitsthe- 
sia  has  been  noticed  ;  the  sphincters  are  not  disturbed.  The  mus- 
cles rapidly  lose  their  faradaic  excitability,  and  the  reaction  of 
degeneration  is  soon  established.  In  this,  in  the  rather  abrupt 
beginning  of  the  palsy,  in  the  muscular  group  involved,  and  in 
the  unexpected  improvements  and  relajises,  we  find  the  main 
differences  from  progressive  muscular  atrophy,  M"hieh  the  disease 
strongly  resembles. 

There  is  another  disease  resembling  progressive  muscular  atrophy 
which  may  be  here  mentioned,  the  singular  affection  endemic  in 
parts  of  Japan,  known  there  as  Kakhe,  and  probably  identical 
with  the  disease  called  in  India  and  Brazil  "  Beriberi."  This 
dangerous  malady  is  a  non-febrile  recurrent  affection,  seemingly 
caused  by  overcrowding,  and  having  as  its  chief  symptoms  exten- 
sive anaesthesia  ;  general  loss  of  muscular  power,  amounting  in  the 
lower  extremities  to  paralysis ;  diminished,  but  not  lost,  electro- 
muscular  contractility  ;  marked  progressive  muscular  atrophy  in 
the  legs ;  dropsical  effusion ;  reflex  vomiting ;  pal])itation,  and 
often  failure  of  the  circulation.*  Recent  researches  make  it 
likely  that  it  is  a  form  of  multiple  neuritis. 

It  is  sometimes  a  matter  of  extreme  difficulty  to  distinguish 
cases  of  what  are  called  idiopathic  atrophy,  or  primary  muscular 
atrophy  whei'e  there  is  no  central  nervous  lesion,  from  the  pro- 
gressive muscular  atrophy  under  consideration.  When  the  former 
disease  happens  in  children  the  distinction  is  not  so  difficult,  for 
the  age,  and  the  facts  that  not  unfrequently  several  members  of  a 
family  are  similarly  affected  and  tiiat  it  tends  to  assume  the  pseudo- 
hypertrophic form,  show  what  it  is.     But  in  adults  there  ma}'  be 

"  Anderson,  St.  Thomas's  Hospital  Reports,  187G. 


DISEASES    OF   THE    BPwMN    AND    SPINAL    CORD.  137 

great  uncertainty.  The  extremely  slow  progress  of  the  disease, 
its  not  unusual  beginning  in  childhood,  the  fact  that  the  hand- 
muscles  escape,  but  that  the  face  is  often  involved  as  well  as 
the  latissimus  and  the  lower  half  of  the  pectoralis,  that  it  affects 
women  as  often  as  men,  and  that  it  is  congenital,  are  some  of  the 
characteristic  points. 

The  difference  in  age  helps  us  to  distinguish  pseudo-hi/pertrophic 
muscular  jmrali/ms  from  progressive  muscular  atrophy.  A  disease 
exclusively  of  childhood,  it  is  characterized  by  weakness  in  the 
lower  limbs  primarily,  the  muscles  of  which,  and  particularly  the 
calves,  increase  greatly  in  size.  Yet,  notwithstanding  this  apparent 
hypertrophy,  there  is  debility,  with  a  waddling  gait,  the  knee-jerk 
is  lost,  extraordinary  attitudes  are  assumed  in  attempting  to  rise 
from  the  ground,  and,  as  the  disease  progresses  and  becomes  more 
general,  complete  paralysis  may  ensue,  with  rapid  dwindling  of 
the  affected  muscles.  These  when  examined  microscopically  show, 
in  the  stage  of  increase,  large  masses  of  interstitial  fatty  matter 
and  an  augmentation  of  the  interstitial  connective  tissue,  and  the 
muscular  fibres  are  in  a  state  of  granular  degeneration. 

Infantile  Paralysis. — In  this  disease,  also  known  as  essential 
paralysis  of  children,  acute  atrophic  paralysis,  and  acute  anterior 
poliomyelitis,  rapid  wasting  of  the  muscles  is  the  striking  feature. 
It  is  pre-eminently  an  affection  of  early  childhood,  and,  as  shown 
by  AVharton  Sinkler,  occurs  much  more  commonly  in  summer 
than  in  winter.  It  happens  most  frequently  during  first  dentition, 
and  is  often  ushered  in  by  fever,  and  by  convulsions  and  other 
cerebral  symptoms.  The  palsy  comes  on  quickly,  generally  before 
the  fever-disturbance  has  passed  away ;  or  an  entire  limb,  or  even 
both  legs  and  arms,  may  almost  from  the  onset  be  aflFected.  In 
any  case  the  palsy  becomes  plainly  discernible  as  the  fever  sub- 
sides. It  is  apt  to  begin  in  one  limb  and  in  a  few  days  to  become 
wide-spread.  But  it  disappears,  except  from  a  particular  region 
in  which  the  muscles  quickly  waste. 

"  Yet  the  palsy  may  at  first  shift ;  it  passes  away  from  some 
limbs,  or  fixes  upon  others  or  upon  different  groups  on  different 
sides  of  the  body.  It  rarely,  however,  remains  as  palsy  of  more 
than  one  side,  and  is  not  associated  with  loss  of  sensibility.  In 
the  absence  of  sensory  symptoms,  as  well  as  in  the  rapid  devel- 
opment of  the  disease,  we  have  the  points  of  difference  which 


138  MEDICAL    DIAGNOSIS. 

.separate  the  wasting  and  j)aralysi.s  that  may  be  due  to  paehymen- 
ingitis  in  the  eervieal  region  from  infantile  palsy  of  the  upper 
extremities.  There  is  often  reeovery  within  six  months  from 
the  onset  of  infantile  paralysis  ;  though  the  dis(H'der  may  last  for 
three  or  four  years,  or  even  mnch  longer.  The  afifeeted  muscles 
arc  apt  to  begin  to  atrophy  after  the  paralysis  has  lasted  a  month, 
and  when  their  wasting  is  marked  they  no  longer  respond  to  the 
faradaic  current,  though  they  may  still  react  strongly  inuler  the 
galvanic  current ;  but  gradually  this  excitability  too  is  lost.  Both 
the  superficial  and  tendon  reflexes  arc  lowered  or  abolished.  After 
six  months  or  a  year  some  faradaic  irritability  is  apt  to  return. 
The  functions  of  bladder  and  rectum  arc  very  seldom  affected. 
In  protracted  cases,  })ermanent  shortening  of  muscles  hapjicns, 
contraction  of  the  joints  takes  place,  and  atrophy  of  portions  of 
the  osseous  system  occurs,  or  rather  a  want  of  its  development  in 
the  blighted  parts,  and  various  and  striking  deformities  result. 

Xow,  the  onset  of  these  eases,  the  occasional  retrocession  from" 
certain  parts,  the  subsequent  course,  and  the  electrical  reactions, 
separate  infantile  paralysis  from  progresdve  muscular  atrophy. 
Then  in  forming  a  diagnosis  we  may  take  into  account  the  extreme 
rarity  with  which  children  are  attacked  \\\i\\  progressive  muscular 
atrophy, — a  disease  of  adults,  and  pre-eminently  of  those  of  the 
male  sex  who  use  their  muscles  continuously  and  violently.  But 
the  affection  may  happen  in  children,  and  then,  as  Duchenne 
points  out,  is  apt  to  show  itself  first  in  the  muscles  around  the 
mouth.  On  the  other  hand,  we  must  not  forget  that  a  disease 
identical  Avith  the  essential  palsy  of  children  is  met  with  in  adults. 
Beginning  acutely  with  febrile  symptoms,  headache,  delirium,  vom- 
iting, and  rheumatoid  jiain  in  the  back,  it  leads  within  a  few  days 
or  less  to  palsy  M'ith  complete  relaxation  of  the  paralyzed  muscles, 
yet  without  impaired  sensibility;  exhibits  but  passing  vesical  dis- 
order; but  shows  soon  disappearance  of  reflex  irritability  and 
wasting  of  the  limbs,  with  or  without  paralytic  contractions,  and 
has  the  lesion  wdiich  has  been  found  in  infantile  palsy,— granular 
degeneration  of  the  cells  of  the  anterior  horns.  This  acute  anterior 
spinal  paralysis  is  not  so  uncommon  as  was  formerly  supposed, 
and  under  the  title  of  acuie  anterior  poliomi/elif is  we  are  becoming 
more  and  more  flimiliar  with  its  clinical  history,  and  arc  learning 
how  often  complete  or  nearly  complete  recovery  from  the  threaten- 


DISEASES    OF    THE    Br.AIX    AND    SPINAL    CORD.  130 

ing  symptoms  takes  place.*  It  is  for  this  reason  tliat  Leyden  f 
asserts  that  many  cases  may  really  begin  in  a  neuritis  and  there 
be  but  very  little,  if  any,  spinal  affection. 

From  the  foregoing  remarks  it  might  be  inferred  tliat  children 
are  only  subject  to  palsies  that  are  spinal.  But  that  is  not  the 
case.  We  find  in  them  a  whole  group  of  cerebral  jjahies, — not 
nearly  so  frequent,  it  is  true,  as  the  spinal  group,  but  palsies 
in  which  the  lesion  is  cerebral,  extending  from  any  part  of  the 
cortex  to  the  gray  matter  of  the  cord,  and  broadly  distinguished 
from  the  spinal  palsy  by  heightened  reflexes,  'unchanged  electrical 
reactions,  loss  of  power  with  disordered  movements  or  spasm, 
and  slight  and  slowly-occurring  muscular  atrophy.  We  may 
find  either  hemiplegia,  bilateral  hemiplegia,  or  paraplegia  as  the 
form  of  paralysis.  In  some  instances  the  affection  follows  de- 
livery with  the  forceps ;  like  spinal  infantile  palsy,  it  has  been 
observed  after  infectious  diseases.  Most  generally  the  disease 
begins  with  fever  accompanied  by  convulsions ;  these  may  be 
followed  by  marked  coma.  The  hemiplegia  is  most  persistent  in 
tlie  arm,  and  is  apt  to  be  associated  with  spastic  contraction,  pro- 
ducing a  peculiar  gait.  Post-hemiplegic  chorea  and  mobile  spasm 
and  athetosis  were  observed  in  a  considerable  number  of  cases 
analyzed  in  Osier's  elaborate  monograph,  j  Convulsive  seizures 
on  the  paralyzed  side  or  general  epilepsy  are  yet  more  common ; 
and  the  intelligence  is  enfeebled. 

In  the  bilateral  form  of  hemiplegia  the  legs  are  more  involved 
than  the  arms ;  spastic  contractions  of  the  muscles  of  the  extremi- 
ties are  most  marked  ;  the  mind  is  very  much  affected  ;  sensation 
is  not  disordered.  Destruction  of  the  motor  centres  of  the  cortex 
is  the  essential  lesion  in  bilateral  spastic  hemiplegia.!  In  the 
spastic  cerebral  paraplegia  of  children  MclSTuttH  found  descending 
degeneration  in  the  pyramidal  tract ;  the  disease  is  limited  to  the 

*  See  literature  and  cases  recorded  by  Seguin,  Transact.  New  York  Acad, 
of  Med.,  1874,  and  "  Myelitis  of  the  Anterior  Horns,"  1877  ;  Wharton  Sinkler, 
Amer.  Journ.  of  Med.  Sci.,  October,  1878;  Althaus,  ih.,  April,  1878;  Erb, 
vol.  xiii.  of  Ziemssen's  Cj-clopEedia ;  Rank,  Deutsches  Archiv  f.  Klin.  Med., 
1880-81. 

t  Zeitschrift  fur  Klin.  Med.,  1880. 

X  The  Cerebral  Palsies  of  Children,  1889. 

§  Osier,  op.  cii. 

II  Amer.  Journ.  of  Med.  Sci.,  vol.  i.,  1885. 


140 


MEDICAL    DIAGNOSIS. 


lower  extremities ;  there  is  no  muscular  wasting-  •  the  gait  is 
stiif  or  cross-leg'oecl.  The  malady  usually  exists  from  birth,  and 
follows  a  diltieult  labor.  The  intellect  is  impaired,  though  not 
always  markedly  so.  AVood*  states  the  affection  to  be  the  result 
of  sclerotic  and  atrophic  changes  in  the  brain. 

Before  ])roceeding,  Ave  will  examine  the  main  forms  of  paralysis 
which  Ave  have  been  studying^  arranged  in  a  tabular  form,  and 
chiefly  with  the  view  of  ascertaining  the  seat  of  lesion,  premising 
that  the  statements  must  be  received  rather  as  generally  true  than 
as  absolutely  so. 

TABULAR  VIEW   OF   PAEALYSIS. 


Symptoms. 
InaLility  to  move  leg  and  arm  of 
one  side.  Sensation  unimpaired, 
or  slightly  impaired.  Incomplete 
paralysis  of  muscles  of  face;  mouth 
drawn  toward  healthy  side.  Elec- 
tro-muscular contractility  preserved ; 
may  be  increased ;  so  may  he  the 
reflex  excitability  of  the  tendons. 


Seat  of  Lesion. 
Corpus   striatum,   involving    internal 
capsule,  both  on  side  opposite  to  the 
palsy. 


Same  symptoms,  but  less  palsy ;  some     Optic  thalamus, 
impairment  of  sensation,  absence  of 
vaso-motor    symptoms,    early    tonic 
and  clonic  spasms  in  hand,  face,  and 
neck. 


Same  symptoms,  but  paralysis  of  face 
on  opposite  side  to  that  of  arm  and 
leg,  and  usually  marked  ;  loss  of  sen- 
sation on  one  side  of  face,  and  uni- 
lateral anaesthesia  or  hyperesthesia 
of  limbs;  giddiness;  nausea.  Height- 
ened temperature  ;  convulsions  ;  con- 
tracted pupil.  Urine  may  contain 
sugar  or  albumen.  Early  rigidity 
of  paralyzed  n.uscles. 


Pons  Varolii,  on  side  opposite  to  palsy 
of  limbs.  The  part  affected  is  be- 
low decussation  of  facial  nerve. 


Same   symptoms,   but  face   paralyzed     Pons  Varolii,  and  at  level  of  decussa- 
on  both  sides.  tion  of  facial  nerve. 


*  ]S'ervous  Diseases  and  their  Diagnosis. 


DISEASES    OF   THE    BRAIN    AND    SPINAL    CORD 


141 


Paralysis  of  arm  and  leg  on  one  side ; 
slight  paralysis  of  face  ;  third  nerve 
paralyzed  on  other  side ;  defective 
sensation,  higher  local  temperature. 

Paralysis  of  motion  of  arm  and  leg, 
incomplete  and  transitory,  soon  fol- 
lowed by  rigidity  ;  no  loss  of  sensa- 
tion. Keflexes,  sujaerficial  and  deep, 
preserved  or  increased.  Localized 
pain  in  head  ;  convulsions. 

Motion  more  or  less  completely 
affected  on  both  sides  of  body ; 
sensibility  diminished  or  lost  on 
one  side,  increased  on  the  other ; 
higher  temperature  on  one  side. 

Both  legs  and  lower  part  of  trunk 
paralyzed  as  to  motion  ;  loss  of  sen- 
sation ;  some  wasting  of  muscles ; 
loss  of  power  over  bladder  and  rec- 
tum ;  reflex  excitability  in  legs 
heightened,  trunk  reflexes  impaired  ; 
electric  contractility  diminished  or 
lost ;  trophic  changes ;  paralysis  of 
muscles  of  respiration  in  some  in- 
stances. 

Both  legs  paralyzed,  muscles  of  legs 
flaccid  ;  feet  extended  ;  ansesthesia  ; 
incontinence  of  urine  from  the  start. 
Superficial  and  deep  reflexes  lost. 
Kapid  wasting  of  muscles.  Keaction 
of  degeneration.     Trophic  changes. 

Arms  as  well  as  legs  paralyzed  ;  other- 
wise symptoms  m.uch  the  same  ;  af- 
fection of  pupils. 

Both  legs  rapidly  paralyzed  as  to  mo- 
tion, relaxation  of  muscles,  sensation 
unimpaired,  only  transient  loss  of 
control  over  bladder  and  rectum ; 
marked  lowering  or  extinction  of 
reflex  excitability  in  the  palsied 
muscles  and  tendons  ;  lost  electro- 
muscular  contractility  to  faradaic 
current ;  rapid  muscular  atrophy  ; 
no  bedsores ;  if  disease  become 
chronic,  muscular  contractions. 


Crus  cerebri  on  side  corresponding  t' 
paralysis  of  third  nerve. 


Cortical  part  of  brain   in  motor  zone 
on  side  opposite  to  palsy. 


Medulla  oblongata  on  side  of  in- 
creased sensibility  and  temperature, 
and  at  level  of  decussation  of  ante- 
rior pyramids. 


In  the  cord  throughout  its  sections 
above  the  lumbar  enlargement,  as 
in  transverse  myelitis  of  the  dorsal 
cord. 


In  the  cord  in  lumbar  enlargement, 
as  seen  in  myelitis  of  these  parts. 


Cervical  region  of  the  cord,  as  in  cer- 
vical myelitis. 

Anterior  horns  of  the  cord,  as  in  de- 
generation of  the  cells  in  acute 
poliomyelitis. 


142  MEDICAL    DIAGNOSIS. 

Ataxia, 

Loss  of  co-ordination  of  niii^eular  niuvenicnt,  Mliicli  in  the 
leos  shows  itself  especially  in  the  gait,  and  in  the  hands  in  the 
ditliculty  of  executing'  delicate  movements,  but  whii-li  strangely 
contrasts  witli  the  muscular  power  that  is  present  in  the  limbs, 
is  found  in  some  neurotic  affections,  as  in  general  paralysis  of 
the  insane,  multiple  neuritis,  and  diphtheritic  paralysis.  But  the 
ataxia  is  most  constant  and  marked  in  locomotor  ataxia. 

Locomotor  Ataxia. — In  this  disorder  we  have  uncertainty 
of  motion  and  seeming  palsy  ;  or,  in  the  words  of  Duchenne, 
who  gave  it  the  name  of  progressive  locomotor  ataxia,  it  consists 
in  "a  progressive  abolition  of  the  co-ordination  of  movement 
with  apparent  paralysis  contrasting  with  the  integrity  of  muscu- 
lar force."  The  patient  is  not  deprived  of  the  power  of  motion, 
but  of  the  power  of  controlling  his  motion  :  hence  he  staggers  in 
his  walk,  or  cannot  walk  at  all  without  support ;  it  is  evident 
that  the  muscles  do  not  obey  the  will. 

Locomotor  ataxia  is  identical  with  a  form  of  palsy  clearly 
recognized  by  Todd,  and  with  the  malady  described  by  Romberg 
as  tabes  dorsaUs;  from  the  lesion  it  exhibits,  it  is  often  called  j^os- 
terior  sclerosis,  degeneration  of  the  posterior  columns  being  its 
main  cause.  In  addition,  recent  observers  have  frequently  found 
a  wasting  of  the  nerve-fibres  of  the  peripheral  spinal  sensory 
nerves. 

The  affection  is  a  very  chronic  one,  lasting  many  years.  It  may 
originate  without  assignable  cause ;  or  may  follow  exposure  to 
cold,  or  injuiy  or  inflammation  of  tlie  cord ;  or  is  hereditary.  It 
is  most  frequently  found  to  be  associated  with  a  history  of  syphilis. 
Among  its  early  symptoms  are  piercing  pains,  lightning-like  or 
similar  to  electric  discharges,  in  the  lower  extremities ;  diplopia  or 
other  disturbances  of  vision,  which  may  be  found  to  be  attended 
with  the  "Argyll-Robertson  pupil," — a  small  pupil  that  does  not 
contract  to  light,  but  does  contract  during  accommodation, — or 
with  paralysis  of  the  sixth  or  the  third  pair ;  and  a  zone  in  which 
sensation  is  greatly  impaired  on  a  level  with  the  third,  fourth, 
fifth,  or  sixth  dorsal  vertebra.* 


Hitzig,  in  Ziemssen's  Cyclopiedia,  article  "  Atrophy  of  Brain." 


DISEASES    OF    THE    BRAIN    AXD   SPINAL    CORD.  143 

Following  these  phenomena,  or  making  its  appearance  at  the 
same  time,  is  a  difficulty  in  co-ordinating  movements  and  in  main- 
taining the  equilibrium  of  the  body.  This  is  manifest  in  attempt- 
ing to  walk  with  the  eyes  closed ;  and  the  patient  is  unable  to 
take  a  single  step,  or  to  stand  erect  with  his  feet  in  juxtaposition, 
without  instantly  losing  his  balance.  True,  this  sign  is  not  pa- 
thognomonic, but  it  is  very  valuable  in  the  diagnosis  of  the  earlier 
stages,  and  so  is  the  difficulty  in  placing  the  foot  on  small  sur- 
faces, in  buttoning  the  clothes,  or  in  walking  backward.  Yet 
the  stumbling  gait  is  not  connected  with  true  paralysis.  The 
muscles  can  act  vigorously,  are  well  nourished,  contract  readily 
when  faradized,  except  in  very  advanced  stages  of  the  disease,  and 
show  neither  tremor  nor  spasm.  The  cutaneous  reflexes  are  gener- 
ally, yet  not  always,  impaired  ;  there  is  absence  of  the  patellar 
tendon  reflex  in  both  knees.  Sensibility  is  markedly  diminished, 
pinching  and  pricking  the  foot  may  scarcely  be  felt,  contact  with 
the  floor  may  not  be  appreciated,  and  the  tactile  sensibility  may  be 
almost  gone ;  but  all  kinds  of  curious  sensations  are  complained 
of.  The  power  to  appreciate  difFerences  of  temperature  may, 
though  it  does  not  always,  remain,  and  there  is  a  delay  in  the 
perception  of  pain.  The  muscles,  too,  lose  their  sensibility.  It 
is  not  unusual  to  have  pains  in  the  region  of  the  fifth  nerve.  The 
intellect  is  unimpaired,  unless  frecpient  attacks  of  vertigo  and  epi- 
leptic seizures  should  be  among  the  symptoms.  The  eyesight  fails 
more  and  more,  there  is  loss  of  color-vision,  and  an  atrophy  of  the 
optic  nerve  may  produce  irremediable  loss  of  sight ;  the  hearing, 
too,  may  become  much  affected  ;  and  signs  of  valvular  disease  of 
the  heart,  especially  of  the  aortic  valve,  show  themselves.  The 
functions  of  the  rectuna  and  bladder  are  not  markedly  disordered, 
though  retention  of  urine  and  sluffffish  action  of  the  bladder  are 
not  infrequent.  There  is  loss  of  sexual  poAver.  Dropsy  and 
local  sweating  are  met  with,  and  so  is  swelling  of  the  joints, 
without  redness  and  usually  without  pain.  But  the  joint  affec- 
tion may  appear,  as  Charcot  has  taught  us,  before  the  loss  of 
power  of  co-ordinating  movement.  In  time,  sometimes  rapidly, 
the  articular  extremities  of  the  bones  disappear,  and  the  joints 
undergo  a  kind  of  dislocation.  The  shafts  of  the  bones,  too, 
show  defects  of  nutrition,  and  spontaneous  fractures  happen.  The 
teeth  drop  out  of  the  atrophied  alveolar  processes ;  the  tendons 


144  MEDICAL    DIAGNOSIS. 

tear ;  the  tongue  may  dwindle  on  one  side ;  the  spine  becomes 
curved.  Herpetic,  bullous,  and  pemphigoid  eruptions  or  ecchy- 
moses  niay  appear  during  or  subsequent  to  exacerbations  of  the 
lightning  pains.  Perforating  ulcer  of  the  foot  has  also  been 
observed  among  the  trophic  changes. 

Among  some  of  the  less  common  symptoms  is  drooping  of  the 
eyelids,  accompanied  by  weakness  of  all  the  muscles  attached  to  the 
eyeball,  so  that  the  movements  of  the  ball  become  much  restricted 
or  wholly  lost.*  Another  symptom,  more  frequent,  however,  is 
the  occurrence  of  spasms  and  pain  in  the  epigastric  region,  with 
attacks  of  vomiting.  These  gastric  crises,  as  they  have  been  termed, 
may  be  found  to  happen  in  those  who  complain  much  of  fulness 
in  the  abdomen  and  of  unsatisfied  hunger.  They  have  even  been 
known  to  lead  to  vomiting  of  blood.  Buzzard  f  shows  the  symp- 
toms to  be  dependent  upon  sclerosis  affecting  the  nucleus  of  the 
vagus.  There  are  also  at  times  attacks  of  laryngeal  spasm  in 
ataxics.  Arthropathies  often  happen  in  those  Avho  present  laryn- 
geal or  gastric  crises.  These  two  forms  of  crises  are  by  far  the 
most  frequent.  But  in  addition  we  have  intestinal  crises,  urethral 
crises,  rectal  crises,  genital  crises,  renal  crises,  cardiac  crises,  and 
others,  in  whicli,  as  the  chief  symptom,  violent  paroxysms  of  pain 
occur,  which  pass  away  and  are  found  not  to  be  connected  Avith 
any  organic  change  of  the  seemingly  diseased  })art.  The  true 
meaning  of  these  pain  crises,  as  well  as  the  distinction  from  the 
visceral  affections  they  simulate,  is  detected  in  the  absent  knee- 
jerk  and  the  other  symptoms  of  the  ataxic  malady. 

There  is  a  chronic  inflammatory  degeneration  of  the  spinal 
cord  having  its  chief  seat  in  the  posterior  columns  and  the  lateral 
pyramidal  tracts,  w^hich  mostly  develops  in  childhood,  is  heredi- 
tary, and  has  as  its  chief  symptom  ataxia.  This  disease  is  known, 
from  the  name  of  the  observer  who  first  accurately  described  it, 
as  Friedreich's  ataxia,  and  is  of  very  long  duration.  The  disorder 
of  co-ordination  shows  first  in  the  low-er  extremities,  and  advances 
upwards,  at  last  affecting  the  organs  of  speech.  Tiic  patellar 
tendon  reflex  is  generally  abolished ;  nystagmus  and  vertigo  are 
frequent;  while  in  the  later  stages  spasms  and  contractions  of. 


*  Hutchinson,  Transact.  Koyal  Medico-Chirurg.  Soc,  1879. 
t  Diseases  of  the  Nervous  System,  1882. 


DISEASES    OF    THE    BRAIN    AND    SPINAL   CORD.  145 

muscles,  (curvature  of  the  spine,  want  of  control  in  keeping  any 
part  of  the  body  quiet,  and  palsies,  are  not  uncommon.  Unlike 
what  takes  place  in  locomotor  ataxia,  there  are  no  disoi'der  of 
cutaneous  sensibility,  no  lancinating  pains,  no  atropliy  of  the 
optic  nerves,  no  Argyll -Robertson  pupil,  no  trophic  lesions,  no 
visceral  disturbances.* 

In  considering  the  diagnosis  of  locomotor  ataxia,  let  us  first 
examine  how  it  differs  from  the  general  paralyds  of  the  insane. 
Both  maladies  are  very  chronic  in  their  course,  and  in  both  there 
is  loss,  or  certainly  impairment,  of  muscular  co-ordination.  In 
the  one  case,  however,  it  exists  with  tremors,  with  thickness  of 
speech,  with  dementia,  but  without  strabismus,  though  with  in- 
equality of  the  pupils,  and  without  the  sharp,  peculiar  pains  of 
ataxia.  Then,  in  this  malady,  the  hands  are  rarely  first  affected ; 
indeed,  when  in  process  of  time  the  upper  extremities  share  in 
the  disorder  there  is  in  them  often  rather  cutaneous  anaesthesia, 
with  some  trembling  and  incomplete  paralysis,  than  an  obvious 
failure  of  co-ordinating  power.  It  must  also  be  remembered  that 
the  two  diseases  sometimes  exist  in  combination. 

With  reference  to  the  distinction  of  progressive  locomotor  ataxia 
from  most  of  the  diseases  of  the  spinal  cord,  it  is  only  necessary 
to  remark  on  the  extreme  rarity  of  muscular  spasm  in  ataxia ; 
from  spinal  paraplegia  the  result  of  myelitis  it  differs  in  the  fact 
that  the  muscles  act  with  strength,  the  patient  can  flex  and  ex- 
tend his  legs  and  kick  vigorously,  while  in  spinal  myelitis  the 
affected  limbs  cannot  move,  though  the  knee-jerk  may  be  exces- 
sive. The  lightning-  or  electric-shock-like  pains  are  not  entirely 
to  be  trusted  to  in  diagnosis,  for  they  may  happen  in  acute  mye- 
litis as  well  as  in  spinal  pachymeningitis  and  in  disseminated 
sclerosis.  The  absence  of  the  knee-jerk  in  locomotor  ataxia  is 
of  great  value.  Its  presence,  in  addition  to  the  tremor  and  the 
scanning  speech,  distinguishes  disseminated  cerebro-spinal  sclerosis. 
But  v/e  must  not  overlook  the  possibility  of  mixed  symptoms 
existing  from  the  different  forms  of  sclerosis  being  combined. 
In  the  disease  to  which  Gowers  has  given  the  name  of  ataxic 
paraplegia  we  have  both  disease  of  the  posterior  and  lateral  col- 


*  For  an  admiraMe  analysis  of  the  recorded  cases  see  Crozer  Griffith's  paper 
in  the  Transactions  of  the  College  of  Physicians  of  Philadelphia,  1888. 

10 


140  MEDICAL    DIAGNOSIS. 

unins  and  u  cDiubinatioii  of  the  symptoms  ot"  spastic  para})legia 
arid  ataxia.  The  knee-jerk  is  excessive,  ankle  clonus  is  present, 
and  there  are  extensor  spasms  in  addition  to  the  incofirdination ; 
but  no  lightning  pains  or  loss  of"  light  reflex  attend  the  ataxia,  as 
in  tabes. 

From  diphtherifie  jxtrdhisls  we  distinguish  tabes  by  the  history 
of  the  malady,  the  absence  of  pain,  and  the  paralysis  of  accommo- 
dation and  of  the  i)alate  ^vhicll  precedes  the  muscular  weakness. 
Loss  of  knee-jerk  exists  in  both,  and  occasionally  incoordination 
is  met  Avith  in  diphtheritic  paralysis.  In  multiple  neuritis  this, 
too,  may  happen  ;  but  the  marked  muscular  and  nerve  tenderness, 
the  changed  electric  reactions,  the  normal  pupils,  the  more  decided 
loss  of  muscular  poAver,  and  the  evidence  of  alcoholism,  tell  the 
true  meanino;. 

A  diminution  or  loss  of  the  muscular  sense — that  guiding  sense 
by  \vhich  we  judge  of  the  position  of  the  limbs,  by  which  we  are 
conscious  of  their  movements,  and  which,  particularly  in  hystei'ical 
patients,  may  become  much  disturbed — occasions  difficulty  in  diag- 
nosis, since  in  locomotor  ataxia  the  muscular  sense  may  be  also  de- 
ficient. On  the  other  hand,  in  the  former  morbid  state  the  motion 
may  be  somewhat  impaired,  for,  as  in  ataxia,  the  feet  may  feel 
numb  in  standing  and  in  walking,  and  the  patient  be  unable  to 
walk  in  the  dark.  But  there  is  this  difference  :  wdiere  merely 
the  muscular  sense  is  affected,  he  can  walk  and  perform  all  move- 
ments, even  those  of  a  complex  nature,  without  vacillation,  so  long 
as  his  eye  is  fixed  on  them  and  superintends  and  gives  them  direc- 
tion ;  Avhile  in  ataxia  the  derangement  of  muscular  co-ordination 
renders,  even  with  the  aid  of  sight,  the  movements  uncertain  and 
irregular.  Then  cutaneous  anajsthesia  is  apt  to  coexist  with  this 
malady.  The  treatment,  too,  will  throw  light  on  a  doubtful  case  : 
the  local  use  of  electricity  will  usually  cure  the  loss  of  muscular 
sense  in  hysterical  paralysis ;  it  has  no  curative  effect  in  ataxia. 

Irrespective  of  the  affection  of  muscular  sense,  the  greatest 
similarity  to  locomotor  ataxia  I  have  seen  has  been  in  several 
cases  of  hysteria;  one  in  particular,  in  a  very  ana?mic  woman, 
resembled  it  closely ;  and  it  may  be  a  question  whetlier  the  nutri- 
tion of  the  parts  affected  in  ataxia  was  not  disordered,  and  the 
nervous  structure  functionally  disturbed.  I  desire  particularly  to 
call  attention  to  these  cases,  which  can  be  distinguished  by  their 


DISEASES    OF    THE    BRAIN    AND    SPINAL    f'OUD.  147 

history,  the  usual  coexistence  of  ansemia,  and  the  absence  of  se- 
vere darting  pains.  Yet  pains  may  also  happen  in  the  hysterical 
comjilaint,  as  in  a  case  I  saw  with  Dr.  Webb;*  but  this  is  un- 
common. Moreover,  the  apparent  want  of  muscidar  co-ordina- 
tion is  more  irregular  in  its  manifestations ;  and  the  cases  re- 
cover. So,  I  think,  may  othei'  cases  of  locomotor  ataxia  due  to 
special  causes.  For  I  have  seen  cases  in  syphilitic  patients,  typical 
in  everything  except  perhaps  the  severity  of  the  neuralgic  pain, 
essentially  typical  in  the  muscular  phenomena  and  in  the  in- 
ability to  walk  with  closed  eyes,  in  which  a  gradual  and  nearly 
complete  recovery  took  j^lace.  Here  the  lesion  was  probably 
removed  or  greatly  influenced  by  the  anti -syphilitic  treatment, 
and  a  true  sclerotic  degeneration  of  the  affected  parts  did  not 
take  place. 

Diseases  of  the  Cerebellum. — Diseases  of  the  cerebellum 
produce  many  of  the  phenomena  regarded  as  peculiar  to  loco- 
motor ataxia.  But  the  gait  of  the  patient  is  that  of  a  drunken 
man :  when  attempting  to  w^alk,  he  leans  to  one  side,  moves  in 
arcs  of  a  circle,  or  describes  zigzags ;  and  when  standing  erect, 
his  body  swings  backward  and  forward,  or  from  side  to  side, 
though  his  feet  remain  quietly  fixed  on  the  ground.  In  ataxia, 
on  the  other  hand,  the  muscular  contractions  in  the  erect  position 
or  during  attempts  at  walking  are  strong  and  sudden,  more  like 
spasms,  yet  not  spasmodic,  and  have  as  their  object  to  keep  the 
body  in  the  line  of  gravity ;  and  the  walk,  though  accomplished 
with  difficulty,  is  straight,  not  reeling ;  the  affected  person,  too, 
while  he  is  walking,  does  not  take  his  eyes  off  the  ground  or  oif 
his  feet,  from  fear  of  fldling  ;  but  he  is  not  giddy.  The  peculiar 
gait  is  particularly  found  when  the  middle  lobe  is  involved. 
Disease  spreading  from  the  cerebellum  gives  rise  to  hypoglossal, 
facial,  and  other  local  palsies.  In  diseases  of  the  cerebellum  we 
find  decided  vertiginous  sensations,  especially  during  attempts  at 
locomotion,  which  may  be  easier  and  straighter  with  the  eyes  shut 
than  with  them  open ;  vomiting,  particularly  at  the  onset  of  the 
complaint,  aggravated  or  brought  on  by  the  erect  posture ;  severe 
headache,  occipital  or  frontal,  when  the  head  is  bent;  defective 
vision,  becoming  very  marked  when  an  object  is  looked  at  for  any 

*  American  Journal  of  the  Medical  Sciences,  Jan.  1876. 


148  MEDICAL    DIAGNOSIS. 

length  of  time,  or  double  vision,  though  the  eye-disturbances  may 
or  may  not  be  associated  with  choked  disk  or  optic  neuritis ;  no 
dTminution  either  of  power  of  motion  or  of  sensibility ;  and  in 
some  instances  rotary  movements  and  hemiplegia.  Rotary  uiov(>- 
ments  are  regarded  as  a  special  proof  of  aft'eetion  of  the  cerebellar 
peduncles.  When  the  disease  is  localized  in  one  hemisphere  of 
the  cerebellum,  it  may  cause  no  symptoms  and  be  beyond  the 
reach  of  diaauosis.*  But  with  reference  to  the  differential  diay:- 
nosis  of  this,  as  of  any  other  form  of  brain  affection  from  loco- 
motor ataxia,  we  may  lay  stress  on  the  occurrence  of  the  shooting 
pains  in  the  latter,  and  on  the  absence  of  the  knee-jerk. 

Tremor. 

Any  involuntary  agitation  of  the  body,  or  of  part  of  it,  with- 
out marked  muscular  contraction  or  impediment  to  voluntary 
movement,  is  called  tremor.  The  trembling  depends  upon  a 
weakening  of  the  muscular  and  nervous  systems.  It  is  common 
in  old  age,  in  convalescence  from  debilitating  diseases,  in  hysteria, 
and  during  chills.  We  also  find  it  in  workers  in  mercury  or  in 
lead,  and  in  those  who  abuse  alcoholic  stimulants  or  coffee,  or 
tobacco,  or  who  are  addicted  to  the  use  of  opium.  In  some  cases, 
as  we  have  seen,  it  is  connected  with  an  organic  disease  of  the 
nervous  centres,  as  in  cerebro-spinal  sclerosis ;  and  it  constitutes 
the  main  symptom  of  the  disorder  known  as  shaking  palsy  or 
paralysis  agitans. 

Tremor  is  easily  recognized.  Yet  it  may  be  confounded  with 
muscular  twitchings.  But  it  differs  from  these  spasmodic  move- 
ments by  being  more  incessant,  and  unconnected  with  decided 
muscular  contractions.  In  nervous,  susceptible  persons  laboring 
under  an  acute  attack  of  disease,  it  is  at  times  combined  with 
great  restlessness,  and  is  apt  to  be  mistaken  for  a  convulsive  state. 
Here  again  it  may  be  distinguished  by  the  absence  of  muscular 
contractions,  and  bv  the  unintermitting  irregular  motions. 

Paralysis  Agitans. — Tremor  is  the  chief  symptom  of  paraly- 
sis agitans.  The  trembling  consists  of  fine  small  movements,  is 
combined  with  muscular  weakness,  or  rather  with  slowness  of  mus- 
cular action,  and,  though  increased  by  exertion  and  mental  excite- 

*  Nothnagel,  Berliner  Klinische  Wochenschrift,  April,  1878. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COIID.  149 

ment,  it  persists  during  rest.  It  usually  follows  continuous  mental 
strain,  emotional  shock,  prolonged  exposure  to  damp,  or  some  de- 
pressing acute  affection  in  elderly  persons ;  it  comes  on  slowly 
and  progresses  slowly  ;  it  generally  begins  in  the  hand  or  foot  and 
gradually  becomes  general.  The  disease  lasts  for  years  :  as  it  ad- 
vances, the  patient  loses  his  equilibrium  in  walking,  leans  forward 
or  walks  on  the  fore  part  of  the  foot,  and  is  rapidly  propelled 
forward.  The  trembling  takes  place  all  over  the  body,  except  the 
head.  It  is  in  more  or  less  continuous  oscillations,  at  first,  at 
least  to  a  certain  extent,  controlled  by  the  will.  The  muscles 
react  to  both  the  faradaic  and  the  galvanic  current.  The  expres- 
sion of  the  countenance  is  vacant  and  fixed ;  the  handwriting  is 
tremulous,  the  voice  piping,  monotonous,  the  speech  indistinct, 
at  times  hurried ;  the  muscles  of  the  extremities  become  rigid, 
especially  the  flexors,  producing  deformities  like  those  of  rheuma- 
toid arthritis.  Sensation  is  little,  if  at  all,  aifected  ;  there  is  great 
restlessness.  Complaints  are  made  of  cramps,  of  muscular  stiff- 
ness, especially  in  the  extremities,  and  of  a  sense  of  excessive 
heat,  associated,  indeed,  with  increased  temperature  of  the  sur- 
face. There  are  no  cerebral  symptoms ;  yet  hypochondriasis  and 
loss  of  intellectual  power  occur  as  the  disease  progresses.  The 
hands  are  apt  to  assume  a  position  as  in  writing.  The  knee-jerk 
is  normal.  In  exceptional  instances  tremors  are  absent.  Of 
the  seat  and  character  of  the  lesion  in  shaking  palsy  we  are  in 
ignorance. 

Multiple  Cerebro-spinal  Sclerosis. — Different  is  the  palsy 
dependent  upon  multiple  or  disseminated  cerebro-spinal  sclerosis, 
or  Charcofs  disease.  The  symptoms  of  this  vary  somewhat,  as 
the  nodules  of  hardened  tissue  affect  the  brain  or  the  cord  first. 
We  have  always  tremor  and  paralysis,  and  if  the  lesion  be  pri- 
marily in  the  brain  the  former  happens  first.  The  trembling  may 
show  itself  from  the  start  in  the  tongue  or  the  eyeball,  and  with 
it  we  usually  find  headache,  vertigo,  failure  of  sight,  nystagmus, 
amblyopia,  impaired  hearing,  and  at  times  gastralgia  and  vomit- 
ing. The  want  of  power  manifests  itself  in  all  the  extremities, 
yet  the  lower  exhibit  the  palsy  most  plainly,  while  tlie  character- 
istic trembling  is  most  evident  in  the  arms  ;  unlike  paralysis 
agitans,  the  paresis  or  paralysis  often  precedes  the  tremor.  Save 
in  rare  instances,  the  trembling  is  not  witnessed  except  when  the 


150  MEDICAL   DIAGNOSIS. 

muscles  are  put  into  motion,  stops,  therefore,  entirely  or  nearly 
so  wheal  they  are  at  rest :  it  is  usually  tested  by  letting  the  patient 
pass  a  glass  of  water  to  his  mouth.  It  occurs  in  decided  jei-ks, 
and  markedly  affects  the  head,  when  this  is  moved  at  all.  Tlie 
gait  is  uncertain  and  tottering,  and  attempts  at  walking  increase  the 
tremor.  The  voice  is  weak,  the  s])eecli  slow  and  scanning  ;  there 
is  mental  enfeeblement,  with  failure  of  nicniorv.  Sensation  is  not 
affected,  nor  are  the  sphincters  ;  but  we  may  have  hypemcsthesia  or 
anaesthesia  or  parsesthesia  and  girdle  pains.  The  tendon  reflexes 
are  generally  exaggerated,  and  foot  clonus  is  not  uncHjmnion. 
Toward  the  end,  muscular  cramps  followed  by  contractions,  and 
disorders  of  deglutition  and  of  respiration,  happen,  or  there  may 
be  attacks  of  an  apoplectic  character.  It  is  in  very  advanced  cases 
only  that  the  electro-muscular  contractility  or  the  galvanic  irrita- 
bility of  the  nerves  is  decidedly  diminished.  Multiple  sclerosis 
is  most  common  between  twenty-five  and  thirty-five,  and  lasts  for 
years.  One  of  its  striking  features  is  that  long  delusive  periods 
of  marked  improvement  occur.  The  description  given  shows  the 
marked  difference  between  it  and  paralysis  agitans. 

There  are  other,  though  far  less  common,  forms  of  tremor, 
connected  with  organic  disease,  such  as  the  post-hcmiplcgic  ircmor 
and  the  tremor  in  spasmodic  tabes.  In  both,  the  history  of  the  case 
and  the  attending  muscular  disorder,  with  the  violent  but  rhyth- 
mical tremors  on  attempted  motion  in  the  latter  affection,  are  of 
great  significance.  As  an  organic  tremor,  too,  may  be  classed  that 
of  old  age.  In  this  senile  tremor  the  trembling  is  most  probably 
due  to  degenerative  changes  in  the  motor  tract  from  the  cortex  to 
the  anterior  cornua.  At  first  it  happens  only  on  voluntary  move- 
ment, stopping  during  repose  and  sleep,  though  ultimately  it  con- 
tinues during  rest  as  well  as  during  motion.  It  begins  in  the 
hands,  but  extends  markedly  to  the  neck  and  head,  and  finally 
becomes  very  much  like  the  tremor  of  paralysis  agitans. 

Functional  Tremors. — There  is  a  group  of  tremors  in  which 
there  is  no  organic  cause,  or  at  least  the  cause  is  so  fine  as  to  elude 
detection.  Toxic  tremors  belong  to  this  group,  and  we  will  look 
at  their  characteristics. 

Alcoholic  tremor  occurs  only  on  movement.  It  is  irregular, 
and  of  considerable  range.  It  is  very  pronounced  in  the  arms, 
face,  and  tongue  ;  in  the  legs  it  generally  shows  itself  only  when 


DISEASES    OF    THE    BRAIN    AND    SPINAL   CORD.  151 

they  are  put  in  action,  as  in  an  attempt  to  staiul.  It  is  associ- 
ated, in  acute  cases  especially,  with  great  restlessness,  and  mus- 
cular twitchings  arc  not  uncommon.  The  trembling  is  usually 
worse  in  the  morning.  Then,  too,  in  its  diagnosis  we  lay  stress 
on  the  habits  of  the  patient. 

Tobacco  tremor  is  a  fine  tremor  which  more  especially  happens 
in  the  hands.  It  is  sometimes  seen  in  the  tongue,  which  is  smooth 
and  shiny,  and  is  apt  to  be  combined  with  a  relaxed  skin,  an 
irritable  heart,  and  feebleness  of  sight. 

Lead  tremor  is  also  a  fine  tremor.  It  is  irregular  in  its  distri- 
bution, increased  by  motion,  and  not  limited.  It  is  often  found 
to  be  associated  with  beginning  weakness  of  the  extensor  muscles 
of  the  forearm,  with  a  blue  line  on  the  gums,  and  may  involve 
the  lips  and  tongue. 

In  arsenical  tremor  the  trembling  is  wide-spread.  There  is 
also  some  difficulty  in  co-ordination,  with  beginning  muscular 
paralysis,  darting  pains  in  the  arms  and  legs,  and  diminution  of 
tactile  sensibility. 

Mercurial  tremor,  another  variety  of  tremor,  is  recognized  by 
observing  that  the  trembling  and  the  incessant  movements  stop 
when  the  shaking  limb  is  supported.  Then  the  gradual  manner 
in  which  the  disease  appears,  its  occurrence  among  persons  whose 
occupations  predispose  them  to  the  absorption  of  mercury,  the 
wakefulness,  the  disorder  of  the  digestive  organs,  and  the  spongi- 
ness  of  the  gums,  form  a  group  of  phenomena  very  characteristic. 

There  is  a  form  of  functional  tremor  which  is  found  to  be  un- 
connected with  any  obvious  cause  and  may  last  through  life. 
This  essential  tremor,  to  call  it  by  that  name,  comes  on  often  in 
young  persons  and  lasts  through  life.  It  shows  itself  most 
markedly  in  the  hands,  is  made  worse  by  excitement  and  by 
attempts  at  motion,  and  to  a  great  extent,  but  not  entirely,  ceases 
during  rest.  It  is  not  associated  with  any  other  motor  disturbance, 
and  I  have  known  it  in  persons  of  high  intellectual  endowments. 
It  may  not  come  on  until  middle  age,  is  not  dangerous,  but  is  not 
curable.  In  an  instance  that  came  under  my  observation  the  father 
and  the  son,  a  young  man,  both  had  it  at  the  same  time  to  an 
equal  degree.  Kindred  to  it  is  the  hereditary  tremor  described  by 
Dana,  which  also  is  a  fine  tremor,  which  does  not  interfere  with 
co-ordination,  and  which  affects  especially  the  upper  extremities. 


152  MEDICAL    DIAGNOSIS. 

It  begins  in  infancy  or  cbildliood  and  eontinncs  durino:  a  lifetime, 
without  shortening  life.  It  is  often  brought  out  by  an  infectious 
fever,  ceases  during  sleep,  and  may  become  associated  with  slight 
contractures  of  the  fingers.* 

Spasms — Convulsions. 

Both  these  terms  are  applied  to  iuvt)hintarv  muscular  contrac- 
tions, with,  perha[)s,  this  dilference  :  the  Avord  spasm  is  used  when 
we  wish  to  express  the  idea  of  less  extensive  muscular  derange- 
ment, but  especially  ^vhen  the  muscles  of  organic  life  are  believed 
to  be  involved ;  and  convulsions,  when  the  disorder  affects  the 
muscles  of  the  whole  body,  or  at  least  many  muscles  at  once,  and 
chiefly  those  of  volition.  Yet  these  are  not  distinctions  that  can 
be  very  strictly  carried  out,  for  the  two  phenomena  often  coexist, 
and,  being  produced  by  the  same  causes  and  obedient  to  the  same 
laws,  can  hardly  be  separated. 

Spasms  may  be  clonic  or  tonic.  In  clonic  spasms  the  muscles 
are  agitated  by  successive  contractions  and  relaxations  of  their 
fibres.  Clonic  spasms  are  very  extensive ;  in  truth,  so  generally 
is  this  the  case  that,  if  we  make  any  distinction  bet^veen  spasms 
and  convulsions,  we  are  bound  to  contemplate  clonic  spasms  as 
convulsions  rather  than  as  spasms.  In  tonic  spasms  the  muscles 
are  rigidly  set,  and  retain  for  a  time  their  contraction,  in  spite  of 
every  effort  on  our  part,  or  on  the  part  of  the  patient,  to  relax 
them.  The  most  marked  type  of  this  disorder  is  seen  in  tetanus  ; 
the  most  perfect  illustration  of  clonic  spasms  is  furnished  by 
hysteria. 

Convulsions  may  be  accompanied  by  a  loss  of  consciousness, 
and  abolished  sensibility,  as  in  epilepsy ;  or  they  may  coexist 
with  unclouded  thought  and  unaltered  sensibility,  as  in  tetanus. 
What  their  immediate  cause  is,  it  is  very  difficult  to  determine ; 
as  yet  we  possess  little  positive  knowledge ;  and  concerning  the 
portion  of  the  nervous  centres  where  they  arise,  or  the  structural 
changes  that  attend  an  attack,  we  are  still  ignorant.  General 
evidence  favoi's  the  cortex  of  the  brain  or  the  medulla  as  being 
the  centres  disturbed  ;  but  the  irritation  need  not  be  direct,  it  may 
be  reflected  to  them.     Of  their  exciting  cause  we  may  say  that, 

*  Amer.  .Journ.  Med.  Sci.,  Oct.  1887. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  153 

iji  those  of  susceptible  nervous  organizations,  any  extrinsic  irri- 
tation, such  as  teething  or  disordered  digestion,  leads  to  a  fit. 
Further  causes  are  diseases  of  the  brain  ;  sudden  interference  with 
the  circulation ;  profuse  hemorrhages ;  ansernia ;  contaminated 
blood  ;  the  toxic  influence  of  lead.  Children  often  have  convul- 
sions as  the  precursors  of  febrile  diseases.  In  point  of  diagnosis 
it  is  of  great  importance  to  distinguish  whether  their  inroad  is  or 
is  not  symptomatic  of  a  cerebral  lesion.  If  there  have  been  a 
previous  disorder  of  the  intellectual  functions,  or  any  other  mani- 
festation of  a  brain  aifection,  we  may  assume  the  convulsions  to 
be  the  signal  of  cerebral  mischief.  But  when  no  such  phenome- 
non is  met  with,  we  are  likely  to  find  the  source  of  irritation  in 
some  other  portion  of  the  body.  Practically  speaking,  when  con- 
vulsions are  among  the  first  signs  of  a  malady,  they  are  apt  not 
to  depend  upon  a  disease  of  the  brain  ;  and  even  if  recognized  to 
form  part  of  the  symptoms  of  a  cerebral  lesion,  we  may  conclude 
that  the  lesion  has  not  reached  its  highest  degree  of  development, 
but  is  still,  as  it  were,  irritative. 

Besides  separating  convulsions  or  spasms  in  conformity  with 
their  centric  or  their  eccentric  origin,  we  must  always  attempt  to 
ascertain  the  particular  nature  of  the  cause.  If  centric,  is  it  con- 
gestion, inflammation,  a  tumor,  sclerosis,  or  other  lesion  of  brain 
or  membranes  ?  or  is  the  convulsion  due  to  influences  the  cosrni- 
zance  of  which  is  not  within  our  horizon?  If  eccentric,  is  it 
owing  to  an  impure  or  impoverished  blood,  to  retained  poisons,  to 
ptomaines,  or  peripheral  from  nerve  lesion  or  intestinal  or  other 
visceral  irritation?  and  what  is  the  probable  sliare  the  reflex 
system  has  in  the  visible  disturbance  of  the  muscles?  To  solve 
these  questions  is  often  very  difficult,  and  nothing  but  a  careful 
analysis  of  all  the  phenomena  of  the  case  enables  us  even  to 
approximate  the  truth. 

Among  the  most  extraordinary  forms  of  spasm  connected  with 
increased  reflex  irritability  of  the  cord  is  the  so-called  saltatory 
spasm,  in  which  so  violent  a  spasm  of  the  legs  takes  place  when 
the  patient's  feet  touch  the  floor  that  he  is  thrown  into  the  air. 
In  some  instances,  as  m  one  described  by  Bamberger,  palpitation, 
dyspnoea,  and  inequality  of  the  pupils  coexisted.  Other  forms 
of  tonic  or  clonic  spasm  happen  in  difl'erent  parts  of  the  body 
from  reflex  irritation  of  certain  nerve-tracts,  and  these  functional 


154  MEDICAL    DIAGNOSIS. 

sjiasms  ]>roclnee  for  tlie  time  being'  tlio  most  singular  contortions 
and  clefo,rmities. 

Closely  associated  witli  spasms  are  other  kinds  of  irregular 
muscular  movements,  such  as  cramps, — a  contraction  of  short 
duration  of  one  or  of  several  muscles,  occurring  in  paroxvsms  and 
attended  with  severe  pain  ;  rigidity, — a  ])ermanent  tonic  contrac- 
tion of  the  muscles,  often  encountered  in  diseases  of  the  brain  ;  and 
the  jerking  movements  of  chorea.  Now,  some  of  these,  esjiecially 
localized  spasm  and  even  rigidity,  have  a  strong  connection  with 
the  seat  and  character  of  the  lesion.  Thus,  broadly  speaking,  if 
we  have  spasm,  perhaps  alternating  with  chorea-like  movements, 
confined  to  one  arm,  one  leg,  one  group  of  muscles,  we  may  infer 
an  irritative  lesion  in  the  cortical  motor  area,  affecting  in  this 
monospasm  the  centre  presiding  over  the  muscular  motion  of  the 
disordered  parts.  Early  rigidity  in  the  muscles,  especially  after 
hemorrhage,  is  apt  to  be  associated  with  increased  faradaic  and  re- 
flex excitabilitv,  but  the  contracted  muscles  become  relaxed  during 
sleep;  in  late  rigidity  the  contraction  or  "contracture"  is  due,  bar- 
ring the  instances  of  hysterical  contracture,  to  descending  degenera- 
tion of  the  fibres  of  the  pyramidal  tract.  In  all  forms  of  contracture 
from  nervous  causes  the  shortening  of  the  muscles  and  the  rigidity 
are  increased  by  movements,  whether  voluntary  or  passive. 

DERANGED    NUTRITION    AND    SECRETION. 

Among  the  subjects  connected  with  the  nervous  system  which 
have  of  late  years  received  most  attention,  there  is  none  of  more 
interest  than  the  association  of  its  disorders  with  derangements 
of  nutrition  and  secretion.  Now,  such  are  manifest  in  paralyzed 
limbs  or  after  nerve-wounds.  But  these  obvious  alterations  need 
here  only  be  referred  to  ;  it  is  the  intention  to  speak  rather  of  the 
less  palpable  phenomena,  the  trophoneuroses  in  which,  at  first 
sight,  the  nervous  svstem  is  not  so  distinctlv  concerned.  For 
instance,  there  is  to  be  noted  the  rapid  development  of  blisters 
and  bedsores  in  connection  with  marked  cerebral  and  spinal 
lesions  ;  the  skin  may  become  the  seat  of  diverse  eruptions,  un- 
dergo modifications  of  color  and  structure,  the  secretions  may  be 
augmented  or  diminished,  the  muscles  and  joints  show  textural 
changes,  swellings  may  happen  affecting  various  portions  of  the 
body,  either  external  or  internal, — yet  all  be  due  to  disturbed 


DISEASES   OF   THE   BRAIN   AND   SPINAL   CORD.  155 

nervous  influence,  and  the  real,  disorder,  therefore,  l)e  in  jiarts 
very  different  from  wlicre  it  appears.  Then  we  find  the  trophie, 
symptoms  of  atrophy  of  the  muscles  in  acute  poliomyelitis  and 
in  Friedreich's  ataxia,  in  the  latter  affection  often  associated  with 
blueness  and  coldness  of  the  feet  from  vaso-motor  change. 

To  ])articularize  with  reference  to  a  few  of  the  derangements 
alluded  to.  There  is  the  affection  known  as  herpes  zoster,  in 
which  the  vesicles  encircling  half  the  circumference  of  the  trunk 
are  not  a  primary  skin  affection,  but  the  local  expression  of  irri- 
tation of  a  nerve.  They  closely  follow  the  distribution  of  some 
superficial  sensory  nerve,  and  this  unilateral  herpes  is  really  but 
a  sign  of  localized  neuralgia, — most  generally  of  a  dorso-inter- 
costal  neuralgia.  Then,  again,  we  encounter  instances  of  large 
vesicles  or  bullse  accompanying  other  neuralgias,  as  of  the  sciatic ; 
and  attacks  of  erysipelas  having  their  origin  in  facial  neuralgia, 
as  has  been  demonstrated  by  Anstie.  Furthermore,  various  kinds 
of  spots  and  blotches,  and  thickenings  of  the  skin,  have  been 
noticed  after  this  and  other  forms  of  neuralgia  ;  and  we  have 
eruptions  of  zoster  in  chronic  myelitis,  and  especially  in  locomotor 
ataxia  limited  to  the  limbs  affected  with  the  pain.  Then,  too,  we 
may  have  eczema  of  nervous  origin  produced  by  reflex  irritation 
in  instances  of  disorders  of  the  urinary  organs  ;*  and  ichthyosis 
of  the  lower  extremities  in  chronic  spinal  diseases. 

Oftentimes,  too,  these  morbid  appearances  on  the  skin  are  com- 
bined with  evidences  of  altered  secretion.  Thus,  in  a  case  re- 
lated by  Parrot,t  in  addition  to  the  neuralgic  paroxysms  attended 
with  sanguineous  exudations  at  the  painful  parts,  there  occurred, 
at  times,  bloody  sweating  of  the  knees,  thighs,  hands,  and  face. 
Lachrymation  was  noticed  in  nearly  half  the  cases  of  trigeminal 
neuralgia  analyzed  by  Notta  ;  |  and  one-sided  furring  of  the  tongue 
is  a  not  uncommon  phenomenon  in  this  complaint.  Associated 
with  these  evidences  of  altered  secretion  may  be  signs  of  altered 
nutrition,  such  as  iritis,  corneal  clouding,  and  inflammation  of 
the  fascia  or  of  the  periosteum  in  contact  with  the  aching  nerve. 
Let  ns  here  add  that  these  manifestations  of  perverted  nutrition 


*  Ord,  St.  Thomas's  Hospital  Reports,  vol.  vii.,  1876. 

f  Gaz.  Hebdom.,  1859;  Handfield  Jones  on  Nervous  Disorders. 

i  Arch.  Gen   de  Med.,  1854. 


156  MEDICAL    DIAGNOSIS. 

are  not  confined  to  neuralgic  disorders.  Trophic  changes  occur 
also  in  diseases  of  the  central  nerv^ous  system.  Thus,  aifections 
of  the  joints  have  been  observed  to  follow  cerebral  hemorrhages, 
and  various  spinal  maladies ;  local  dryness  of  the  skin  occurs  in 
unilateral  atrophy  of  the  face;  a  form  of  joint-mischief,  of  hy- 
drarthrosis, has  been  specially  described  in  locomotor  ataxia  by 
Charcot;  and  the  perforating  ulcer  oftlie  foot  lias  been  found  by 
Ball  *  and  Fayard  f  to  be  often  connected  with  the  same  disease. 
Perforating  ulcer  of  the  foot  has,  however,  also  been  found  in 
Morvan's  Disease,  an  aifection  in  which  localized  sweats,  par- 
onychias, and  recurring  ulcerations  and  necrotic  processes  attend 
other  trophic  changes  J  of  a  peripheral  neuritis. 

CEdema  happens  also  as  a  vaso-motor  change.  AVeir  Mitchell  § 
points  out  swelling  of  the  limbs  in  menstrual  periods.  Further- 
more we  find  local  oedematous  swellings  occurring  in  various  parts 
of  the  body  associated  with  intestinal  disturbance,  and  this  angio- 
neurotic oedema  has  been  noticed  by  Osier  ||  to  affect  members  of  a 
family  for  five  generations. 

Among  the  phenomena  of  altered  secretion  connected  with 
nervous  affections,  one  of  the  most  striking  is  excessive  sweating. 
In  lesions  of  the  cervical  sympathetic  on  one  side,  we  may  have 
strictly  unilateral  sweating  of  the  face  and  neck,  the  other  side 
remaining  perfectly  dry  ;^  and  greater  vascularity  and  increased 
temperature  are  concomitants.  In  lesions  of  the  abdominal  gan- 
glia, profuse  sweating  also  happens,  and  is  apt  to  be  combined 
with  impeded  secretion  from  the  mucous  coats  of  the  bowels,  as 
we  at  times  find  in  instances  of  abdominal  aneurism.  Not  that' 
excessive  sweating,  whether  localized  or  general,  is  always  linked 
to  an  affection  of  the  great  sympathetic  ganglia.  AVe  find  local 
sweatings  limited  to  the  hands  and  feet  without  any  signs  of 
other  disorder.  And  general  sweatings,  irrespective  of  those  of 
colliquative  character  attending  phthisis,  or  of  those  of  malarial 
diseases,  happen  after  low  fevers,  in  inactive  states  of  the  liver, 

*  Trans,  of  Internat.  Med.  Congress,  vol.  ii.,  London,  1881. 

t  These  de  Paris,  1881. 

t  Monod  and  Eeboul,  Arch.  Gen.  de  Med.,  July,  1888. 

^  Amer.  Journ.  of  Med.  Sci.,  July,  1884. 

II  Ibid.,  April,  1888. 

^  As  in  the  case  recorded  by  W.  Ogle,  Med.-Chir.  Trans.,  vol.  lii. 


DISEASES    OF    THE    BRAIN    AND    SPINAL   CORD.  157 

and  in  some  persons  go  on  for  years  without  obvious  cause.  It 
may  be  that  in  most  if  not  in  all  of  these  cases  the  sympathetic 
system  is  really  at  fault,  at  least  in  so  far  that  there  is  a  reflex 
derangement  of  the  vaso-motor  nerves,  and  of  course,  then,  of 
the  subcutaneous  blood-vessels  and  of  the  glands  they  supply. 

But  these  are  not  questions  which  we  can  here  consider.  In- 
deed, the  ivhy  and  the  hoio  of  all  these  changes  of  secretion  and 
nutrition  attending  nervous  affections  are  still  very  uncertain. 

To  return  to  the  clinical  phenomena.  Besides  the  external 
manifestations  of  altered  secretion  and  nutrition,  there  are  certain 
changes  in  internal  organs,  the  expression  of  nervous  derange- 
ment. There  is  exophthalmic  goitre ;  the  pneumonia  that  results 
from  injury  to  the  vagus ;  the  ophthalmia,  which  may  even  pass 
on  to  perforation  of  the  cornea,  that  happens  after  paralysis  of  the 
trigeminus  ;  the  kidney  disease  which  follows  chronic  spinal  affec- 
tions. And  the  Medicine  of  the  Future  will  most  likely  acquaint 
us  with  many  more  disorders  of  glands  and  viscera  which  originate 
in  altered  nerve-structure  and  in  perverted  power. 

So  much  for  the  chief  manifestations  of  nervous  complaints. 
From  the  preceding  pages  it  will  have  become  apparent  how  many 
of  them  are  functional,  or  are  at  least  of  necessity  so  regarded, 
and  how  these  functional  disorders  may  be  attended  with  the  signs 
of  as  great  disturbance  as  the  organic  maladies.  And  nothing 
is  more  difficult  than  to  fix  their  seat ;  for  after  death  not  the 
slightest  structural  alteration  may  be  discernible,  or  it  may  be  of 
a  character  insufficient  to  account  for  the  phenomena  during  life. 
In  consequence,  there  is  confusion,  and  doubt  is  throw^n  over  any 
anatomical  or  pathological  classification  of  nervous  diseases.  I 
subjoin  a  table  of  the  main  affections,  arranged  according  to  their 
supposed  sites.  It  may  not  suit  a  strict  critic,  since,  in  several  of 
the  disorders  regarded  as  functional,  modern  research  has  indicated 
the  probable  organic  cause.  But  from  the  point  of  view  of  the 
physician  it  would  be  premature  to  recognize  a  fixed  lesion,  and 
I  contend  rather  for  the  classification  being  useful  clinically  than 
unimpeachable  pathologically.  Nor  will  it  be  adhered  to  in  the 
description  of  nervous  affections,  which  will  be  traced  according  to 
divisions  formed  by  groups  of  symptoms  rather  than  in  obedience 
to  a  pathological  classification. 


158 


MEDICAL    DIAGNOSIS. 


TABLE  OF  THE  AFFECTIONS   OF  THE  BRAIN  AND   SPINAL   CORD. 


Cerebral  , 


Organic - 


Functional. 


Organic. 


Cerebro-Spinal    . 


Functional. 


Spinal.. 


C  Hypenvniia. 

AiKuiiiia. 

Mi'iiingitis  in  its  various  forms. 

Hydrocephalus. 

Abscess. 

Softening. 

Sclerosis. 

Hemorrhage  (Apoplexy). 

Thrombosis. 

Embolism. 

Tumors,  etc. 
[  Syphilitic  affections. 

Delirium. 

Insanity? 

Hypochondriasis. 

Headache. 
[  Trance. 

r  Cerebro-spinal  meningitis. 

Disseminated  cerebro-spinal  sclerosis. 

Paralysis  agitans. 
[  Hydrophobia. 

Epilepsy. 

Catalepsy. 

Ecstasy. 
I    Chorea. 
I   Hysteria  ? 
L  Neurasthenia, 
f  Hypersemia. 

Anaemia. 

Spinal  meningitis. 

Myelitis  in  various  forms. 

Softening. 


.  J   Atrophy. 

Orqanic i    o  i 

^  I   Sclerosis. 


Functional. 


Locomotor  ataxia. 

Spinal  apoplexy. 

Tumors,  etc. 

Syphilitic  affections. 
1^  Progressive  muscular  paralysis. 
'  Spinal  irritation. 

Spinal  exhaustion. 

Tremor. 

Tetanus. 

Keflex  spasms  due  to  irritation  of  the  cord. 


■       DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  159 

Acute  AflPections  of  which  Delirium  is  a  Prominent  Symptom. 

This  clinical  group  cmljraces  the  different  forms  of  meningeal 
inflammation,  delirium  tremens,  and  acute  mania, — affections  in 
all  of  which  the  brain  is  the  seat  of  the  disturbance. 

Acute  Meningitis. — By  this  term  is  understood  an  inflam- 
mation of  the  membnmes  of  the  brain,  especially  of  the  arach- 
noid and  of  the  pia  mater.  The  dura  mater  is  far  less  frequently 
attacked ;  very  rarely,  unless  the  morbid  action  be  of  syphilitic 
origin,  or  have  extended  from  the  bones  of  the  cranium,  or  have 
resulted  from  an  injury. 

The  disease  generally  presents  two  well-marked  stages.  The 
first,  or  the  stage  of  excitement,  is  characterized  by  intense  head- 
ache, great  restlessness,  vomiting,  a  hard,  frequent  pulse,  fever,  in- 
jected eye,  often  with  a  contracted  pupil,  strabismus,  an  increased 
sensibility  to  light  and  sound,  obstinate  constipation,  irregular 
respiration,  and  soon  by  active  delirium,  and  by  convulsions. 
The  second  stage  is  marked  by  an  evident  ebbing  of  the  life- 
forces  :  the  extremities  are  cold,  the  pupils  dilated,  the  pulse  is 
feeble  and  much  slower,  and  intermitting,  or  becomes  extremely 
rapid  and  thread-like ;  involuntary  passages  occur ;  there  is  utter 
loss  of  mind  and  of  sensibility, — in  one  word,  coma  or  collapse. 
In  this  stage  the  temperature  may  fall  below  the  normal,  or,  on 
the  other  hand,  may  exceed  106°. 

Not  every  case,  however,  has  all  these  symptoms,  or  goes  at 
once  from  the  stage  of  excitement  to  that  of  collapse.  There  may 
be  a  well-defined  period  of  transition,  during  which  the  heat  of 
skin,  except  of  the  head,  diminishes,  drowsiness  appears,  and  the 
pulse  sinks  somewhat  in  frequency.  Again,  the  disease  may  be 
arrested  before  the  signs  of  prostration  are  very  evident. 

The  attack  may  be  preceded  by  sick  stomach,  buzzing  in  the 
ears,  and  vertigo,  or  it  may  set  in  with  severe  pain  fixed  to  the 
forehead  and  increased  by  movement.  In  some  cases  it  begins 
with  delirium  or  convulsions.  On  the  other  hand,  these  signs 
may  be  absent.*  Among  the  symptoms  of  the  affection,  even  in 
the  earliest  stages,  a  persistent  pain  attacking  one  or  both  knees, 
violent,  intensified  on  motion,  unrelieved   by   local  means,  and 

*  In  a  paper  by  Church,  in  St.  Bartholomew's  Hospital  Eeports,  vol.  iv., 
several  cases  without  delirium  are  narrated. 


IGO  MEDICAL    DIAGNOSIS. 

connet'tal  neither  with  swcllino-  nor  with  anv  other  chansic  in  the 
form  or  ajijH'aranee  of  tlie  joint,  has  been  particuhirly  noticed.* 

The  niahuly  may  ])ass  rapidly  throngh  its  stages,  so  rapidly  that 
their  distinctive  features  become  confused  and  blended.  Generally 
it  does  not  last  less,  or  much  more,  than  a  week. 

Acute  meningitis  is  brought  on  by  alcoholism,  by  exposure,  by 
depressing  cares,  by  intense  application  to  study,  by  a  blow  or 
fall  upon  the  head,  by  disease  of  adjacent  structures,  or  by  syphilis. 
It  sometimes  affects  mainly,  or  wholly,  the  coverings  of  the 
convex  portion  of  the  brain  ;  at  other  times  the  inflammation 
is  limited  to  the  base.  Meningitis  of  the  convexity  is  very  apt  to 
be  purulent,  and,  if  purulent,  temperatures  of  104°  to  105°  are 
usual.  It  generally  comes  on  suddenly,  and  is  found  to  be  con- 
nected with  disease  of  the  bones  of  the  skull,  with  ear  disease,  or 
to  follow  exposure  to  the  rays  of  the  sun.  Severe  headache,  hy- 
pera?sthesia,  rigidity  of  the  neck,  spasms  in  the  facial  muscles  of 
one  side  and  in  one  or  both  arms,  are  among  the  most  marked 
symptoms. 

According  to  Duchatelet,t  meningitis  of  the  base  may  be  dis- 
criminated by  remissions  in  the  delirium,  and  by  the  coexistence 
of  spasmodic  symptoms  with  profound  and  early  coma.  These 
signs,  at  all  events,  are  said  to  be  distinctive  in  children,  who, 
more  than  adults,  are  disposed  to  this  form  of  the  complaint.  In 
some  cases  acute  muscular  pains  with  defective  motor  power,  a 
clear  mind  until  late  in  the  disorder,  a  temperature  of  105°,  have 
been  specially  noticed.^  Moreover,  the  long  duration  of  the 
malady, — for  it  lasts  for  weeks, — with  the  delirium  of  varying 
intensity,  not  occurring  soon,  the  intervals  of  clearness,  and  the 
late  and  incomplete  palsies,  is  regarded  as  very  significant  of  this 
simple  basilar  meningitis.§  Then  persistent  vomiting  and  early 
optic  neuritis  point  to  the  base.  Optic  neuritis  is  indeed  rare  in 
meningitis  of  the  convexity.  Yet  there  is  no  certainty  in  the 
diagnosis.  Nor  can  we  be  sure  of  the  membrane  chiefly  involved 
in  the  meningeal  inflammation.  Inflammation  of  the  dura  mater 
has  the  least  severe  and  striking  symptoms. 

*  Lund,  quoted  in  Amer.  Journ.  of  Med.  Sci.,  Oct.  1864. 

■f-  Inflammation  de  I'Arachnoide,  p.  230. 

j  Dowse,  Medical  Times  and  Gazette,  Feb.  1874. 

g  Huguenin,  in  Ziemssen's  Cyclopaedia. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  161 

Acute  meningitis  is  not  always  easy  of  diagnosis.  Leaving 
out  for  the  present  the  other  disorders  belonging  to  the  same 
group,  such  as  acute  mania  and  delirium  tremens,  it  may  be  con- 
founded with 

Cerebritis  ; 

Acute  Softening  ; 

Head  Symptoms  of  Continued  Fevers  ; 

Head  Symptoms  of  Acute  Rheumatism  ; 

Head  Symptoms  of  Acute  Ulcerative  Endocarditis; 

Head  Symptoms  of  Pneumonia  ;  of  Peeicarditis. 

Cerebritis. — ^There  is  little  appreciable  difference  between  in- 
flammation of  the  brain-tissue  and  inflammation  of  the  meninges. 
In  truth,  what  we  commonly  call  meningitis  is  not  unfrequently 
also  cerebritis  ;  since  the  diseased  process  extends  readily  from  the 
tunics  of  the  brain  to  the  adjacent  cerebral  substance.  We  may 
suspect  this  structure  to  have  become  involved,  if  the  sense  of 
vision  or  of  hearing  be  suddenly  perverted ;  if  the  convulsions, 
the  agitation  of  the  limbs,  and  the  tremors  be  very  marked;  if 
they  occur  chiefly  upon  one  side ;  and  if  coma  succeed  rapidly 
to  the  period  of  excitement,  and  be  accompanied  or  preceded  by 
one-sided  palsy. 

Aoute  Softening. — The  form  of  acute  softening  which  sinmlates 
meningitis  is  that  associated  with  delirium.  But  it  occurs  only 
in  very  old  persons,  is  apt  to  be  preceded  by  restlessness,  some 
mental  confusion,  and  signs  of  a  general  breaking  up  of  nerve- 
force,  is  soon  associated  with  disturbances  of  the  bladder  and 
rectum,  and  leads  to  coma.  In  the  cases  which  I  have  seen  there 
was  neither  much  headache  nor  febrile  disorder. 

Head  Symptoms  of  Continued  Fevers. — In  all  the  varieties  of 
continued  fever,  but  especially  in  typhoid  and  typhus,  cerebral 
S}'mptoms  at  times  arise  which  bear  a  strong  resemblance  to  those 
of  idiopathic  meningitis ;  and  such  symptoms  may  appear  with- 
out the  examination  of  the  dead  body  showing  even  traces  of  in- 
flammation. How,  then,  are  we  to  distinguish  these  fever  cases 
from  meningitis  ?  or  how  ascertain  if  meningeal  inflammation  be 
really  before  us  as  a  complication,  as  it  sometimes  is,  of  the  fever? 
Unfortunately,  there  is  no  sign  absolutely  diagnostic.  The  in- 
crease of  phosphates  in  the  urine,  thought  to  furnish  a  valuable 
source  of  distinction,  as  indicating  an  inflammatory  affection,  may 

11 


162  MEDICAL    DIAGNOSIS. 

be  due  to  other  causes.  Nor  does  cerebral  auscultation  afturd 
us  any  help ;  for  the  few  authors,  such  as  Fislier,*  Wiiitney,| 
Roger,!  Jurasz,§  who  have  at  all  investigated  the  subject,  are  not 
even  agreed  whether  the  blowing  sound  that  is  perceived  is  con- 
stantly present  in  meningitis,  wliether  it  may  not  exist  in  any 
cerebral  disturbance,  nay,  whether  it  may  not  be  heard  in  health. 
As  matters  stand,  a  diagnosis  can  be  established  only  by  a  care- 
ful consideration  of  all  the  symptoms,  and  of  the  history,  espe- 
cially of  the  onset ;  by  searching  for  the  eruption  of  typhus  or 
typhoid  fever ;  by  taking  note  of  the  expression  of  the  counte- 
nance ;  by  the  character  of  the  delirium,  ordinarily  so  much  more 
active  when  the  brain  or  its  membranes  are  inflamed,  and  attended 
with  throbbing  of  the  arteries  of  the  neck  and  face, — a  symptom, 
however,  not  conclusive,  for  I  have  repeatedly  noticed  it  in  low 
fevers, — and  not  unfrequently  with  convulsions.  Then,  too,  Ave 
may  lay  stress  on  optic  neuritis ;  on  retraction  of  the  head,  if 
present ;  on  the  more  intense  headache ;  on  the  vomiting ;  and 
we  may  attach  some,  but  not  too  great,  importance  to  the  red  line 
made  by  drawing  the  nail  across  the  forehead, — the  meningitic 
streak.  The  most  valuable  diiferential  sign  is  the  loss  of  the 
knee-jerk,  an  absence  which  is  at  least  temporarily  apt  to  happen 
in  meningitis.  But  how  difficult  it  may  be  ordinarily  to  arrive 
at  a  correct  conclusion,  unless  we  possess  a  full  knowledge  of  all 
the  circumstances,  is  shown  by  this  case  : 

A  man,  about  thirty-five  years  of  age,  was  admitted  into  the 
Philadelphia  Hospital  some  years  ago,  with  a  certificate  that  he 
was  laboring  under  typhoid  fever.  No  clue  could  be  obtained  to 
the  history  of  the  malady.  He  himself  was  not  in  a  state  to  an- 
swer questions.  His  pulse  was  excessively  feeble,  and  somewhat 
irregular ;  the  eye  was  not  injected,  but  suffused  and  watery ;  the 
pupils  were  sluggish,  and  the  eyeballs  in  constant  motion ;  the 
tongue  was  dark,  dry,  and  fissured  ;  the  breath  offensive.  There 
appeared  to  be  pain  on  pressure  in  the  I'ight  iliac  fossa,  but  the 
bowels  were  constipated,  and  no  eruption  could  be  detected.  The 
most  striking  feature  of  the  case  was  the  delirium,  which  was 

*  Amer.  Journ.  of  Med.  Sci.,  Aug.  1838. 

flbid.,  Oct.  184.S. 

X  Ibid.,  Oct.  1862. 

II  Schmidt's  Jahrbiicher,  No.  7,  1878. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COUD,  163 

noisy  and  violent  and  accompanied  by  great  restlessness ;  the  man 
sang,  screamed,  was  constantly  attempting  to  get  out  of  bed  and 
to  upset  his  medicine-bottle.  The  malady  did  not  seem  to  be 
typhoid  fever ;  the  symptoms  belonged  more  to  inflammation  of 
the  brain  ;  but,  knowing  neither  how  nor  when  the  delirium  had 
begun,  a  positis^e  conclusion  was  not  reached.  The  patient  died 
the  day  after  his  admission  into  the  hospital.  The  autopsy 
showed  the  intestines  to  be  sound.  The  membranes  of  the  brain, 
after  the  dura  mater  was  removed,  were  found  to  be  opaque,  and 
between  the  convolutions  were  shreds  of  lymph  and  a  puriform 
liquid.  There  were  only  traces  of  inflammation  at  the  base,  ex- 
cept in  the  neighborhood  of  the  pons  Varolii,  where  some  lymphy 
effusion  was  discerned.  The  ventricles  were  filled  with  fluid,  and 
the  nervous  structure  in  the  neighborhood  of  the  thalami  and 
corpora  striata  was  softened. 

Subsequent  to  the  man's  death  it  was  ascertained  that  he  had 
been  ill  for  only  four  days  before  he  entered  the  ward ;  which 
fact,  had  it  been  previously  known,  would  have  materially  assisted 
in  ari-iving  at  the  diagnosis.  Irrespective  of  the  difficulty  of  its 
recognition, — a  difficulty  which  now,  with  our  knowledge  of  the 
eye-ground  and  of  the  reflexes,  would  not  be  so  great, — this  case 
is  of  peculiar  interest.  It  illustrates  the  possibility  of  the  absence 
of  convulsions  and  of  paralysis  notwithstanding  the  most  evident 
cerebral  disorganization. 

Head  Symptoms  of  Acute  Rheumatism.. — In  rheumatic  fever 
cerebral  symptoms  occasionally  arise  which  may  be  referred  to 
inflammation  of  the  brain,  or  which,  by  their  prominence,  may 
mislead  the  practitioner,  causing  him  to  regard  the  signs  of  the 
rheumatism  as  of  little  importance,  if  indeed  he  do  not  wholly 
overlook  them.  The  morbid  manifestations  are  very  much  like 
those  of  acute  meningitis :  restlessness,  headache,  and  violent  de- 
lirium, succeeded  by  coma.  The  delirium  is  commonly  of  gradual 
approach,  but  it  may  come  on  suddenly.  Generally  it  does  not 
appear  until  the  patient  has  been  suffering  for  at  least  a  week  with 
acute  rheumatism  ;  and  the  heavy  sweats  and  swollen  joints  point 
out  the  malady  with  which  it  is  combined. 

Examinations  of  the  head,  in  cases  which  have  proved  rapidly 
fatal,  fail  to  detect,  save  in  rare  instances,  any  evidences  of  in- 
flammatory action  within  the  cranium.     The  abnormal  signs  are, 


164  MEDICAL    DIAGNOSIS. 

as  a  rule,  more  properly  attributable  to  the  rheumatic  poison 
seizing  upon  the  brain,  and  to  the  altered  condition  of  the  blood. 
Thev  are  at  times  found  to  be  connected  with  the  setting  in  of 
inflammation  of  the  membranes  of  the  heart,  or  of  pneumonia, 
or  with  albuminuria,  or  with  plugs  of  fibrin  in  the  capillaries 
of  the  brain,  and  are  frequently  associated  with  a  very  high 
temperature* 

Head  iSymptoms  of  Acute  Ulcerative  JEndocanUtis. — The  severe 
headache,  the  delirium,  the  somnolence,  which  may  attend  ulcera- 
tive endocarditis  may  cause  it  to  be  confounded  with  meningitis. 
Generally,  however,  the  fever  is  of  a  typhoid  type ;  and  the  high 
temperature,  the  rigors,  the  marked  swelling  of  the  spleen,  are 
very  significant,  and  so  of  course  are  the  cardiac  murmurs. 

Head  Si/mptoms  of  Pneumonia  ;  of  Pericarditis. — In  both  these 
maladies  delirium  may  be  met  with  of  a  character  so  violent  as  to 
lead  to  the  belief  that  the  brain  or  its  membranes  are  involved  in 
an  inflammatory  disease.  The  diagnosis  is  cleared  up  by  a  careful 
examination  of  the  chest.  Then  we  may  lay  stress  on  the  furious 
delirium  being  unattended  with  spasmodic  movements  or  with 
paralysis.  The  form  of  pneumonia  which  is  mostly  associated 
with  delirium  is  inflammation  of  the  upper  lobes.  True  menin- 
gitis sometimes  attends  pneumonia,  and  is  with  great  difficulty 
distino-uished  from  the  mere  disturbance  of  the  cerebral  circula- 
tion  just  mentioned,  unless  persistent  vomiting  and  pressure  on 
a  cranial  nerve  show  us  the  real  meaning  of  the  brain  aiFection. 

Tubercular  Meningitis. — This  is  a  rare  disease  in  adults ; 
not  a  rare  disease  in  children.  Indeed,  nearly  all  the  cases  of 
so-called  acute  hydrocephalus,  and  most  of  those  of  meningitis 
of  the  base,  are  instances  of  tubercular  meningitis,  or,  to  define 
the  morbid  state,  of  an  inflammation  of  the  meninges  occurring  in 
tubercular  patients,  and  ordinarily  accompanied  by  the  deposition 
of  tubercles  at  the  base  of  the  brain,  and  by  effusion  into  the 
ventricles. 

The  premonitory  signs  of  the  malady  are  of  great  importance. 

*  For  a  collection  of  cases,  I  may  refer  to  a  paper  on  Cerebral  Eheumatism 
■which  I  published  in  the  American  Journal  of  the  Medical  Sciences,  Jan. 
1875.  Dr.  Posner,  in  the  German  translation  of  this  book,  points  out  that 
the  use  of  salicylic  acid,  now  so  much  employed,  may  give  rise  to  confusing 
cerebral  symptoms,  such  as  headache,  vertigo,  hallucinations,  even  delirium. 


DISEASES   OF   THE   BRAIN   AND   SPINAL   OORD.  165 

The  child  has  generally  been  ailing  for  some  time  ;  is  restless, 
peevish,  sleeps  badly,  complains  of  headache,  and  is  troubled  with 
a  frequent,  short  cough,  and  with  constipation.  To  these  symp- 
toms are  soon  added  thirst,  a  slightly-coated  tongue,  vomiting, 
a  dry,  feverish  skin,  an  accelerated  pulse,  and  grinding  of  the 
teeth,  constituting  the  prominent  features  of  the  first  stage  of  the 
affection.  After  four  or  five  days  the  second  stage  is  reached, 
and  the  brain  symptoms  become  more  clearly  developed.  The 
child  shuns  the  light,  puts  the  hand  frequently  to  its  head,  and 
utters  now  and  then  a  peculiar,  sharp,  distressing  cry.  At  night 
the  headache  becomes  worse,  and  is  attended  with  fleeting  de- 
lirium. A  slight  strabismus  is  observable,  and  the  eyeballs  oscil- 
late. The  pulse  is  very  irregular  in  its  rhythm,  sometimes  rapid 
and  intermitting,  then  suddenly  falling  and  becoming  quite  slow. 
The  vomiting  ceases,  and  there  may  be  a  remission  in  the  symp- 
toms, with  restored  intelligence ;  but  the  pulse  remains  irregular, 
the  temperature  is  moderately  elevated,  the  bowels  are  even  more 
constipated  than  before,  and  the  abdomen  appears  retracted.  The 
third  stage  is  one  of  complete  stupor,  accompanied  or  preceded  by 
convulsions.  The  expression  of  the  face  is  idiotic ;  the  pupils 
are  dilated ;  there  is  subsultus,  and  one  side  of  the  body  is  para- 
lyzed. Deglutition  is  difficult ;  the  surface  is  covered  with  cold 
sweats.  This  condition,  so  painful  to  behold,  may  last  for  days; 
repeated  convulsions  hasten  its  termination. 

Can  we  distinguish  this  formidable  complaint  from  ordinary 
meningitis  f  Seldom  from  meningitis  of  the  base  ;  generally  from 
meningitis  of  the  convexities.  As  regards  the  discrimination  from 
the  former  malady,  we  are,  it  is  true,  sometimes  enabled  to  pro- 
nounce the  affection  to  be  tubercular  meningitis,  if  we  are  familiar 
with  the  patient's  antecedents,  and  are  cognizant,  previous  to  the 
seizure,  of  the  presence  of  scrofula  of  bones  or  joints,  or  of 
tubercle  in  any  of  the  internal  organs,  or  are  able  at  the  time 
to  detect  scrofulous  glands  or  tubercular  phthisis.  But  without 
knowledge  of  this  kind  a  positive  diagnosis  is  impossible  :  we 
have,  notwitlistanding  symptoms  of  basilar  meningitis,  nothing 
to  direct  us  except  the  probability  that  the  case  is  tubercular,  be- 
cause most  instances  of  meningitis  of  the  base  are  of  that  nature. 
This  uncertainty  does  not  exist  with  reference  to  the  usual  form 
of  simple  meningeal  inflammation.     We  may  generally  distin- 


166  MEDICAL    DIAGNOSIS. 

guisli  the  tubercular  malady  by  its  occurrence  in  an  unliealtliy 
pei-son ;  by  its  insidious  approach  ;  by  the  absence  of  violent  de- 
lirium ;  by  the  appearance  of  convulsions,  not  early,  but  late  in 
the  disease ;  by  the  far  less  violent  headache,  and  the  less  degree 
of  febrile  excitement ;  by  the  notable  remissions  in  several  of  the 
cerebral  signs ;  by  the  chest  symptoms,  and  the  long  duration  of 
the  affection.  The  ophthalmoscojx;  gives  no  certain  information  ; 
tubercles  are  not  commonly  found  in  the  eye-ground,  only  optic 
neuritis  or  choked  disks. 

Tubercular  meningitis  is  ordinarily  attended  with  an  eifusion  of 
serum  into  the  ventricles,  and  it  is  plain  that  many  of  the  symp- 
toms are  attributable  to  pressure  of  the  fluid  on  portions  of  the 
bmin.  Now,  ho\v  can  we  separate  the  malady  acute  hydroceph- 
alus, as  it  used  to  be  called,  from  dropsy  of  the  brain,  or  chronic 
hydrocepliolus  F  Partly  by  the  history  of  the  case,  and  partly 
by  the  normal  size  of  the  head ;  for  the  water  on  the  brain  is 
not  sufficient  in  amount  nor  is  it  there  long  enough  to  ])roduce 
an  appreciable  augmentation  of  tlie  cranium.  Then,  in  chronic 
hydrocephalus  the  symptoms  manifest  themselves  for  years,  from 
childhood  even  to  adult  life.  The  signs  of  a  profound  cerebml 
lesion  appear  gradually,  the  special  senses  are  by  degrees  en- 
feebled, but  it  is  a  long  time  before  they  are  wholly  abolished, 
or  before  complete  loss  of  consciousness  takes  place. 

As  regards  the  diagnosis  between  tubercular  meningitis  and 
acute  hydrocephalm,  it  need  only  be  stated  that  the  latter  affection 
is  in  the  vast  majority  of  cases  a  synonyme  for  the  former.  Yet 
we  occasionally  meet  with  instances  in  which  acute  hydrocephalus 
occurs  unconnected  with  tubercle.  It  then  either  runs  a  latent 
course,  or  appears  as  an  acute  malady  with  symptoms  similar  to 
those  of  acute  meningitis,  commencing  either  with  fever  or  with 
convulsions,  and  often  attended  with  intense  restlessness,  succeeded 
by  drowsiness,  and  having  periods  of  intermission  of  the  symp- 
toms and  of  apparent  improvement.  Toward  the  end  convul- 
sions are  common.  The  complaint,  unlike  tubercular  meningitis, 
happens  in  previously  healthy  children,  begins  suddenly,  and  is 
of  short  duration.  But  the  eifusion  may  remain,  and  the  disorder 
lead  to  chronic  hydrocephalus. 

There  is  a  functional  disturbance  of  the  brain  of  great  imjjor- 
tance  to  discriminate  from  tubercular  meningitis, — the  hydrocc2)h- 


DISEASES    OF   THE    BRAIN    AND    SPINAL    CORD.  107 

aloid  disease  described  by  Marshall  Hall.  It  has  a  stage  of  irri- 
tability, and  a  stage  of  torpor :  a  stage  in  which  the  little  patient 
is  restless,  feverish,  and  a  stage  in  which  the  countenance  becomes 
pale,  the  breathing  irregular,  the  voice  husky,  and  the  pupils 
are  uninfluenced  by  light.  These  symptoms  indicate  nervous  ex- 
haustion. They  generally  come  on  after  an  enfeebling  attack  of 
illness,  especially  subsequent  to  protracted  diarrhoea  or  loss  of 
blood ;  sometimes  they  follow  premature  weaning.  In  the  his- 
tory of  the  case ;  in  the  less  tendency  to  vomiting ;  in  the  irregu- 
larity of  the  pulse  ;  in  the  flaccid  and  hollow  state  of  the  fontanel, 
so  dissimilar  to  its  prominent  and  tense  condition  in  inflamma- 
tion ;  and  in  the  arrest  of  the  threatening  signs  by  stimulants 
and  by  tonics, — we  find  the  guides  which  enable  us  to  decide 
against  the  existence  of  an  organic  disease  of  the  brain  or  its 
membranes. 

But  other  affections  besides  those  of  the  brain  may  be  con- 
founded with  tubercular  meningitis,  such  as  typhoid  fever  and 
pneumonia.  From  typhoid  fever  tubercular  meningitis  may  be 
distinguished  by  the  frequent  vomiting ;  by  the  retracted  ab- 
domen, so  unlike  the  swollen,  tender  belly  of  enteric  fever ;  by 
the  constipation  instead  of  the  diarrhoea ;  by  the  normal  size  of 
the  spleen  ;  by  the  irregularity  of  the  pulse ;  by  the  occurrence  of 
convulsions  and  ansesthesia  and  other  signs  of  profound  motor 
and  sensorial  disturbance,  and  by  the  lower  heat,  the  thermometer 
seldom  rising  above  102°.  I  have  never  seen  an  eruption  in 
tubercular  meningitis ;  but  Barthez  and  Rilliet  speak  of  fugitive 
imperfectly-formed  rose-spots  being  present  in  rare  cases.  The 
duration  of  the  two  complaints  aifords  no  help  in  diagnosis,  since 
the  one  may  last  as  long  as  the  other. 

Tubercular  meningitis  is  often  mistaken  for  the  typhoid  fever 
of  childhood ;  indeed,  there  are  many  points  of  close  resemblance 
between  them.  Yet,  except  in  those  rare  cases  of  coexisting  acute 
tuberculization  of  the  intestines,  we  do  not  perceive  in  the  cerebral 
disorder  a  tongue  red  at  the  edges,  diarrhoea,  and  other  manifesta- 
tions of  intestinal  irritation ;  and  vomiting  and  nausea  are  more 
prominent  and  protracted  symptoms  than  in  the  febrile  malady. 
But  in  this  complaint  the  temperature  is  generally  much  higher  ; 
the  pulse  is  quicker,  yet  not  unequal  and  subject  to  such  de- 
cided variations  ;  delirium  occurs  much  earlier,  and  is  much  more 


168  MEDICAL    DIAGNOSIS. 

marked, — indeed,  tubercular  meningitis  may  run  through  all  its 
stages  without  mental  \\andering. 

In  reviewing  the  maladies  with  which  tubercular  meningitis 
may  be  confounded,  it  is  incumbent  upon  us  to  bear  in  mind  the 
inflammatory  ajf'cctlons  of  the  lungs,  which,  in  children  csi)ecially, 
are  not  uncommonly  associated  with  delirium  and  other  brain 
symptoms.  But  the  cerebral  phenomena  take  a  d liferent  course ; 
the  febrile  excitement  is  more  intense  ;  and  an  examination  of  the 
chest  reveals  the  cause  of  the  disturbance  of  the  brain.  Yet  we 
must  not  overlook  the  fact  that  the  signs  of  acute  phthisis  may 
be  like  those  of  acute  bronchitis  or  of  acute  pneumonia ;  that 
hence  it  may  become  a  very  perplexing  subject  to  determine  the 
precise  cause  of  the  disordered  respiration.  In  adults  the  diffi- 
culty is  far  less,  because  the  demonstration  of  the  existence  or 
non-existence  of  pulmonary  tubercle  is  much  easier.  As  an  im- 
portant point  in  the  diagnosis  of  the  tubercular  meningitis  of 
children,  with  reference  to  the  chest  symptoms,  Gee  *  mentions 
that  the  chest  heaves  equally  well  on  both  sides,  yet  over  a  very 
large  part,  or  even  the  whole,  of  one  side,  no  respiratory  sound 
is  heard. 

Tubercular  meningitis  is  not  so  rare  in  adults  as  has  been 
supposed,  and  presents,  as  Seitz  in  his  admirable  monograph  has 
shown,  marked  features  of  pain  in  the  head  and  temperature 
variations,!  exhibiting  a  fever  of  moderate  type,  with  irregular 
remissions.  The  deposit  of  tubercle  both  in  adults  and  in  chil- 
dren may  not  be  confined  to  the  head.  Indeed,  the  observations 
of  Liorilli  J  teach  that  the  spinal  cord  is  frequently  implicated. 

The  points  of  the  diiferential  diagnosis  of  the  tubercular  men- 
ingitis of  adults  are  much  the  same  as  with  reference  to  the 
disease  in  childhood.  Yet  one  disorder  is  more  apt  to  be  con- 
founded with  it, — hysteria.  Indeed,  in  young  women  the  onset 
of  the  malady  may  develop  very  misleading  hysterical  symptoms. 
But  on  close  examination  we  find  the  traits  of  the  cerebral  malady, 
— the  temperature  record  of  the  attending  fever,  the  unequal 
pupils,  the  divergent  strabismus,  the  optic  neuritis,  the  trophic 


*  Reynolds's  System  of  Medicine,  vol.  ii. 

f  Die  Meningitis  tuberculosa  der  Erwachsenen. 

X  Archives  de  Physiologic,  1870. 


DISEASES    OF   THE   BRAIN   AND   SPINAL   CORD.  169 

changes  in  the  skin,  the  incontinence  of  urine,  the  hjcal  begin- 
ning; of  the  convulsions. 

Cerebro-spinal  Meningitis. — Now  and  then  cases  of  men- 
ino-itis  are  encountered  in  whicli  the  inflammation  affects  simul- 
taneously  the  membranes  of  the  brain  and  of  the  spine,  and  in 
which  the  symptoms  of  the  cerebral  malady  are  found  to  be 
blended  with  severe  pain  along  the  vertebral  column,  with  retrac- 
tion of  the  head,  with  convulsions,  with  rigidity  of  the  muscles, 
with  perverted  cutaneous  sensibility, — in  short,  with  the  phenom- 
ena denoting  spinal  meningitis.  But  such  sporadic  cases  are  of 
rare  occurrence.  Generally  cerebro-spinal.  meningitis  is  not  met 
with  save  as  an  epidemic  disease  which  presents  itself  in  some- 
what dissimilar  forms,  changing  mainly  as  the  cerebral  or  the 
spinal  disturbance  prevails,  and  belongs  clearly  to  the  group 
of  fevers,  with  which  it  will  be  described.  But  here  may  be 
pointed  out  the  extreme  difficulty  of  recognition  of  the  sporadic 
non-epidemic  cases.  The  early  retraction  of  the  head,  the  erup- 
tions, and  the  increasingly  high  temperature  of  cerebro-spinal 
fever  are  the  most  valuable  diagnostic  signs.  Pneumonia,  so 
common  in  this,  may,  as  some  cases  mentioned  by  Gowers* 
prove,  also  happen  in  the  sporadic  malady. 

Delirium  Tremens. — The  prominent  trait  of  this  complaint 
is  delirium,  associated  with  trembling  and  witii  sleeplessness.  It 
occurs  in  intemperate  persons ;  yet  such  is  not  always  the  case,  for 
we  may  find  an  affection  identical  with  mania  a  potu  in  those  who 
are  not  intemperate  in  the  ordinary  acceptation  of  the  word,  but 
whose  nervous  system  has  been  racked  by  persistent  mental  anxiety, 
or  by  the  use  of  other  than  alcoholic  stimulants.  I  have  seen  such 
cases  from  the  constant  taking  of  cliloral  and  of  paraldehyde  ;  and 
Levinstein  notices  the  same  in  those  who  are  addicted  to  the  use 
of  morphine.f 

Generally,  however,  delirium  tremens  is  brought  on  by  the 
abuse  of  intoxicating  liquors.  It  is  a  current  belief,  and  one 
which  has  found  much  favor  among  habitual  drinkers,  that  a 
diminution  or  a  sudden  discontinuance  of  the  accustomed  bev- 
erage is  followed  by  an  onset  of  delirium.     This  may  perhaps 

*  Diseases  of  the  Nervous  System,  1888. 
t  Die  Morphiumsucht,  Berlin,  1877. 


170  MEDICAL   DIAGNOSIS. 

happen ;  but,  if  I  am  to  take  as  a  standard  the  large  number 
of  casesof  the  disorder  Avhich  have  come  under  my  care  at  the 
PhiUidelphia  and  Pennsylvania  Hospitals,  I  should  say  that  its 
appearance  is  most  commonly  preceded  by  a  long-continued  and 
unusually  severe  debauch,  which  finds  its  winding  up  in  an  attack 
of  mania ;  hence  that  this  occurs  in  consequence  of  an  excess, 
rather  than  of  a  diminution,  of  the  habitual  stimulus. 

Let  us  look  a  little  more  closely  at  the  mental  wandering.  It 
is  very  rarely  tierce ;  nor  is  the  patient  taken  up  wholly  Avith  his 
delusions.  He  pays  a  certain  amount  of  attention  to  surrounding 
objects,  answei'S,  perhaps  in  a  rambling  manner,  the  questions  put 
to  him,  but  fancies  that  animals  are  running  around  on  his  bed 
or  are  crawling  on  the  walls,  and  is  thereby,  or  by  some  equally 
distressing  illusion,  kept  in  horror  and  in  dread.  Or  he  imagines 
himself  to  be  engaged  in  his  ordinary  occupations,  and  gives  minute 
directions  as  to  what  he  Avishes  done ;  tries  to  get  out  of  bed,  yet 
is  quite  tractable  when  thwarted  in  his  efforts.  His  hands  are 
constantly  moving,  and  his  delirium,  to  use  the  graphic  epithet  of 
Watson,  is  a  busy  one.  With  it  are  associated  great  sleeplessness, 
a  frequent,  soft  pulse,  a  moist,  coated  tongue,  and  a  clammy  skin. 

How  are  we  to  distinguish  the  malady  from  one  to  which  it 
bears  a  certain  resemblance, — acute  meningitis  f  Taking  clearly- 
expressed  examples  of  each,  we  find  the  following  marks  of  dis- 
tinction :  the  pulse  is  different ;  tense  and  hard  in  meningeal 
inflammation,  it  is  yielding  and  soft  in  delirium  tremens.  The 
skin  and  tongue  are  dry  and  feverish  in  the  former  affection,  moist 
in  the  latter.  Then  the  characteristics  of  the  delirium  are  dis- 
similar :  and  in  the  one  disease  the  mental  Avandering  is  combined 
with  severe  headache,  but  not  with  tremors ;  in  the  other,  with 
tremors,  but  not  with  headache. 

Yet  in  actual  practice  the  diagnosis  is  not  always  so  easy  as  it 
might  appear  to  be  at  first  sight,  and  here  and  there  we  meet  with 
cases  presenting  symptoms  the  exact  meaning  of  which  it  is  puz- 
zling to  determine.  The  difficulty  is  mainly  occasioned  by  extreme 
cerebral  congestion,  or  by  inflammatory  action,  having  been  pro- 
duced by  the  same  exciting  cause  that  has  brought  on  delirium 
tremens.  In  this  blending  of  two  morbid  states,  the  pulse  is,  or 
soon  becomes,  tenser  than  in  pure  mania  a  potu ;  the  skin  is  hotter  ; 
and  I  believe  the  irritability  of  the  stomach  is  more  marked  and 


DISEASES   OF   THE   BRAIN   AND   SPINAL   COIID.  171 

more  persistent.  In  some  instances,  convulsions,  strabismus,  and 
deep  stupor — carefully  to  be  distinguished  from  the  sleep  which 
often  announces  the  termination  of  mania  a  potu — set  all  doubt 
at  rest.  But  when  these  signs  are  not  present,  we  have  to  judge 
of  the  mischief  that  is  going  on  within  the  cranium  chiefly  by  the 
vascular  excitement,  and  by  the  activity  of  the  fever.  Yet  caution^ 
is  necessary  in  accepting  as  evidence  phenomena  which  may  be  of 
diverse  origin  :  the  fever  may  be  the  result  of,  what  is  very  fre- 
quent in  delirium  tremens,  an  intercurrent  or  coexisting  pneumo- 
nia, of  a  gastritis,  or  of  a  pulmonary  apoplexy,  as  in  a  case  I  saw 
at  the  Philadelphia  Hospital  in  July,  1860. 

There  is  another  point  connected  with  the  diagnosis  of  the 
malady  which  it  is  necessary  to  mention,  and  chiefly  for  the  pur- 
pose of  calling  attention  to  a  common  error.  The  fact  that  a 
person  known  to  be  of  bad  habits  is  affected  with  delirium  is 
received  as  a  sure  indication  that  the  mental  delusions  have  been 
produced  by  the  abuse  of  ardent  spirits.  But  they  may  be  owing 
to  other  causes :  to  fever ;  to  a  visceral  inflammation ;  to  acute 
mania.  To  avoid  being  deceived,  we  must  lay  stress  rather  on 
the  special  character  of  the  delirium,  and  on  the  symptoms  with 
which  it  is  combined,  than  on  its  mere  presence.  In  other  words, 
delirium  in  inebriates  is  not  of  necessity  the  fruit  of  intemperance. 
In  discussing  acute  mania  we  shall  return  to  this  subject. 

When  delirium  tremens  ends  fatally,  death  takes  place  from 
exhaustion.  The  fatal  issue  is  occasionally  brought  on  by  an 
intercurrent  inflammation,  especially  of  the  lung,  or  by  disorder 
of  the  kidneys  and  uraemia.  Sometimes,  after  the  subsidence  of 
the  urgent  cerebral  symptoms,  the  patient  dies  very  unexpectedly, 
and  there  are  no  morbid  appearances  in  the  brain  or  its  mem- 
branes to  account  for  the  abrupt  extinction  of  life.  In  many 
instances,  however,  of  these  sudden  deaths,  a  large  amount  of 
serum  is  found  in  the  ventricles,  or  in  the  subarachnoid  spaces. 

Acute  Mania. — It  would  be  obviously  out  of  place  to  attempt 
to  give,  in  a  work  of  this  kind,  a  detailed  account  of  any  of  the 
forms  of  insanity  ;  but,  in  its  acute  variety  especially,  it  resembles 
other  affections  of  the  nervous  system  so  closely  that  it  cannot  be 
wholly  passed  over. 

There  are  mainly  two  disorders  with  which  acute  mania  is  liable 
to  be  confounded, — acute  meningitis  and  delirium  tremens ;  and 


172  MEDICAL   DIAGNOSIS. 

we  shall  for  our  purposes  best  learn  the  manifestations  of  acute 
mania  by"  contrasting  it  with  these  maladies. 

From  acute  meninffitis  mania  differs  in  these  essential  par- 
ticulars :  the  jiremonitory  symptoms  of  the  former  are  headache, 
drowsiness,  and  often  a  sense  of  tingling  and  of  numbness  in  the 
extremities ;  tliese  signs  are,  however,  soon  succeeded  by  the  se- 
verer headache,  tense  pulse,' decided  fever,  and  optical  illusions  of 
the  developed  disease.  The  premonitory  symptoms  of  acute  mania, 
on  the  other  hand,  have  generally  existed  for  a  longer  time  before 
tlie  mai'ked  outbreak  ;  some  singular  change  of  mannei"  or  of  mode 
of  thought  commonly  precedes  the  first  violent  attack  of  insanity, 
except  in  those  cases  in  which  the  overthrow  of  reason  results 
from  a  sudden,  great  grief,  or  from  a  violent  shock  to  the  nervous 
system.  Further,  when  the  delusions  have  taken  full  possession 
of  the  mind,  the  patient  attempts  to  act  up  to  them,  and  his  bodily 
strength  enables  him  to  do  so.  He  has  little  if  any  fever;  no 
spasms ;  his  pupils  are  not  contracted ;  his  stomach  is  not  irri- 
table ;  he  does  not  suffer  from  headache,  or  at  least  does  not  in 
any  way  complain  of  his  head.  It  is  needless  to  point  out  how 
all  this  differs  from  acute  inflammation  of  the  brain. 

There  is  but  little  difficulty  in  discriminating  between  typical 
cases  of  delirium  tremens  and  of  acute  mania.  The  anxious  coun- 
tenance, the  alarm,  the  good-natured  loquacity  and  restlessness  of 
the  patient,  his  moist  skin,  compressible  pulse,  and  creamy  tongue, 
are  very  different  from  the  ravings  and  excitement,  or  the  stub- 
born silence  alternating  with  the  wild  hallucinations,  of  insanity. 
Yet  there  are  cases  in  which  it  is  not  easy  to  tell  if  the  delusions 
are  really  due  to  intemperance  :  cases  of  insanity  excited  by  drink 
in  persons  predisposed  to  mania.  It  may,  indeed,  at  first  be  im- 
possible to  decide  upon  their  nature,  and  upon  the  share  the  drink- 
ing has  in  their  production.  A  few  days,  however,  ordinarily 
remove  all  uncertainty  :  the  person  who  was  thought  to  be  merely 
delirious  is  seen  to  become  frantic  after  an  intermission  of  quiet, 
or,  unlike  what  happens  in  mania  a  potu,  to  be  still  out  of  his 
mind  after  he  has  had  several  sound  sleeps.  In  one  instance,  in 
which  much  doubt  existed  as  to  the  diagnosis,  the  patient  solved 
the  doubt  by  jumping  out  of  bed  after  having  been  quietly  sleep- 
ing for  hours,  and,  in  a  state  of  wild  excitement,  knocking 
down  the  nurse  who  tried  to  prevent  her  from  leaving  the  room. 


DISEASES    OP   THE    BRAIN    AND    SPINAL    CORD.  173 

Furthermore,  in  acute  alcoholic  mania  there  is  a  strong  tendency 
to  homicide,  while  in  acute  melancholia  induced  by  drink  the 
tendency  is  to  suicide. 

Diseases  marked  by  Sudden  Loss  of  Consciousness  and  of 
Voluntary  Motion. 

The  chief  diseases  of  this  class  are  apoplexy,  sun-stroke,  and 
catalepsy.  Epilepsy,  too,  might  here  be  regarded  ;  but  it  will  be 
more  convenient  to  consider  it  with  the  convulsive  affections. 

Apoplexy. — This  is  coma  coming  on  rapidly,  in  consequence 
of  the  compression  of  the  brain  by  extravasated  blood.  At  all 
events,  hemorrhage  is  the  condition  by  far  the  most  common ;  in 
comparatively  rare  cases  only  does  the  pressure  upon  the  brain 
result  from  turgescence  of  the  vessels,  or  from  an  effusion  of 
serum. 

The  malady  has  sometimes  no  prodromata ;  but  not  unfrequently 
it  is  preceded  by  great  depression  of  spirits,  by  attacks  of  loss  of 
memory,  by  illusions,  by  vitiated  perceptions,  by  vertigo,  by  odd 
sensations  in  the  head,  or  by  one-sided  weakness  or  numbness. 

The  seizure  is  generally  sudden,  and  the  coma  quickly  devel- 
oped. The  patient  falls  to  the  ground,  bereft  of  all  consciousness. 
In  other  instances,  before  he  sinks  into  the  comatose  sleep,  there 
will  be  more  or  less  pain  in  the  head,  sickness  at  the  stomach, 
heaviness  and  confusion  of  thought,  or  even  slight  convulsions. 
Such  gradual  cases,  Abercrombie  tells  us,  are  more  dangerous 
than  those  of  abrupt  origin.  Again,  we  may  even  have  convul- 
sions a  prominent  feature  almost  from  the  onset. 

When,  whatever  the  beginning,  the  attack  has  reached  its 
height,  it  presents  these  well-known  features  :  the  patient  lies  as 
if  in  a  deep  sleep,  breathing  laboriously  and  noisily,  and  each 
snoring  inspiration  is  followed  by  a  flapping  of  the  cheeks  in  ex- 
piration. The  pulse  is  slow,  full,  at  times  irregular ;  the  carotids 
throb  violently,  and  the  increased  pulsation  is  particularly  noticed 
in  large  effusions ;  there  is  difficulty  of  deglutition ;  the  pupils 
are  immovable,  and  either  contracted  or  dilated ;  the  eye  is  half 
open;  there  is  conjugate  deviation.  All  thought,  all  sensation, 
all  volition,  is  suspended ;  the  limbs  are  motionless,  flaccid,  and 
when  lifted  fall  passively  and  to  all  appearance  lifeless  to  the 
ground.     Occasionally  their  muscles  are  rigid ;  but,  save  when 


174  MEDICAL   DIAGNOSIS. 

the  apoplexy  is  very  extensive,  reflex  contractions  can  be  excited 
in  them,"  or,  to  speak  more  accurately,  on  the  paralyzed  side  the 
patellar  tendon  reflex  is  exaggerated,  while  the  siiperticial  reflexes 
are  absent.  In  severe  cases  the  insensibility  becomes  greater,  the 
reflex  action  is  abolished,  the  breathing  becomes  very  irregular, 
of  tlie  Cheyne-Stolvcs  variety,  and  involuntary  discharges  take 
place  from  bladder  and  rectum. 

If  the  patient  recover  from  the  comatose  state,  he  does  so  gen- 
erally in  a  short  time :  in  a  few  liours,  unless  the  lesion  be  very 
great,  the  intellectual  faculties  begin  to  resume  their  sway,  and 
all  the  functions  of  the  body  are  slowly  restored  to  their  natural 
condition.  Yet  there  is  a  palpable  exception  to  this  in  the  mus- 
cular system.     Paralysis  of  one  side  is  apt  to  remain. 

The  temperature  \'ariations  in  apoplexy  may  be  turned  to  useful 
diagnostic  account.  The  temperature  of  the  body  is  at  first  low- 
ered by  several  degrees,  but  this  is  followed  by  a  stationary  normal 
period  and  not  unfrequently  by  a  rapid  rise,  which  again,  as  the 
patient  recovers,  is  succeeded  by  a  return  to  the  natural  body  heat. 
In  severe  cases  where  large  hemorrhages  take  place,  the  tempera- 
ture never  rises,  or  only  rises  to  fall  with  the  recurrence  of  the 
fatal  bleeding.  If  the  stationary  period  be  short  or  absent,  and 
the  body  heat  rise  therefore  almost  continuously  after  the  primary 
depression,  the  prospects  of  recovery  are  also  gloomy. 

Apoplexy  is  very  apt  to  happen  after  dinner  and  during  sleep, 
and  is  most  common  ^vhen  sudden  variations  of  temperature  are 
most  frequent.  Liddell  has  shown  that  attacks  are  more  usual 
in  the  spring.  In  New  York  he  found  the  mortality  greatest  at 
that  time  of  year.*  One  attack  of  apoplexy  is  likely,  sooner  or 
later,  to  be  followed  by  another ;  and  the  reason  of  this  is,  that 
the  predisposing  cause  is  generally  of  a  persistent  character, — an 
organic  cardiac  malady,  especially  hypertrophy  of  the  left  ventricle 
or  tricuspid  regurgitation .;  Bright's  disease ;  degeneration  of  the 
cerebral  arteries ;  disseminated  sclerosis,  or  softening  of  the  brain. 
It  is  likely  that  the  extravasation  of  blood  is  generally  due  to  the 
same  immediate  cause, — to  rupture  of  miliary  aneurisms  on  the 
minute  diseased  arteries. 

Now,  is  there  anything  at  the  time  of  the  apoplexy,  or  after  its 

*  Treatise  on  Apoplexy,  New  York,  1873. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  175 

most  urgent  symptoms  have  passed  away,  by  which  wc  can  recog- 
nize whether  the  pressure  on  the  brain  results  from  a  chjt,  from 
a  serous  effusion,  or  from  a  turgescence  of  the  cerebral  vessels? 
And,  again,  do  the  morbid  manifestations  furnish  any  clue  to  the 
seat  of  the  hemorrhage  ?  With  reference  to  the  former  question, 
all  clinical  experience  forces  us  to  admit  that,  in  any  of  the  states 
mentioned,  the  actual  signs  may  be  the  same,  and  that  we  never 
can  be  quite  certain  of  the  non-existence  of  a  clot.  It  is  true 
that  when  the  ai^oplectic  symptoms  abate  rapidly ;  when  thought, 
however  confused,  soon  returns ;  when  the  limbs  are  not  paralyzed, 
or  are  so  but  imperfectly  and  for  a  short  time,  we  have  strong 
reason  for  believing  that  congestion,  simply,  lies  at  the  root  of  the 
disturbance ;  that,  in  other  words,  the  case  is  one  of  those  called 
simple  apoplexy.  But  it  is  never  possible  to  give  a  positive 
opinion,  since  a  clot  near  the  periphery  of  the  brain  may  occasion 
the  same  phenomena  as  those  specified.  Attacks  of  cerebral  con- 
gestion with  apoplectic  symptoms  happen  in  the  general  paralysis 
of  the  insane.     The  features  of  this  point  out  their  nature. 

With  regard  to  a  rapid  effusion  of  serum,  the  difficulty  of  dis- 
tinction from  hemorrhage  is  very  great.  In  fact,  the  only  differ- 
ential signs  which  were  formerly  claimed  for  serous  apoplexy, 
namely,  pallor  of  face  and  feebleness  of  pulse,  are  common  in 
large  sanguineous  effusions ;  and  when  we  analyze  the  symptoms 
of  the  cases  recorded  by  Abercrombie,  by  Morgagni,  and  by  An- 
dral, — for  the  descriptions  of  older  authors  respecting  this  affection 
are  not  to  be  trusted,  and  most  modern  authorities  seem  to  pass  it 
by  as  unworthy  of  notice, — we  find  absolutely  nothing  that  can  be 
looked  upon  as  conclusive.  In  a  case  which  came  under  my  ob- 
servation some  years  since,*  the  respiration  w^as  not  noisy,  nor  was 
there  flapping  of  the  cheeks,  or  the  least  discernible  movement 
of  any  portion  of  the  body ;  yet  none  of  these  points  can  be  re- 
garded as  diagnostic.  Most  of  the  cases  of  so-called  serous  apo-' 
plexy  are  instances  of  Bright's  disease  with  serous  effusion  into  the 
brain. 

The  seat  of  the  hemorrhage  can  be  detected  with  more  certainty 
than  the  cause  of  the  cerebral  pressure ;  it  could  be  detected  with 
greater  certainty  were  it  not  that  the  extravasation  so  often  takes 

*  Charleston  Medical  Journal  and  Eeview,  March,  1859. 


176  MEDICAL   DIAGNOSIS. 

place  into  an  already  diseased  brain.  In  the  majority  of  instances 
the  blood  is  effused  into  one  of  the  corpora  striata  and  the  internal 
capsule  or  at  the  same  time  into  the  optic  thalami,  and  we  find 
only  one-sided  paralysis.  If  the  lesion  be  in  both  hemispheres, 
the  palsy  is  on  both  sides  of  the  body,  although  more  complete 
on  one  side  than  on  the  other.  Yet  a  double-sided  palsy  does 
not  justify  an  absolute  opinion  that  the  extravasation  of  blood 
into  the  brain-substance  is  double-sided.  It  betokens  also  an 
effusion  into  the  ventricles.  But  ventricular  hemorrhage  is  distin- 
guished by  profound  coma  and  by  tonic  contraction  of  the  muscles, 
or  by  tonic  alternating  with  clonic  spasms,  and  rigidity  of  the 
muscles  either  on  one  or  on  both  sides  occurs ;  the  respiration  is 
much  embarrassed,  and  the  breath-sounds  are  obscured  by  rales. 
It  is  common  in  the  very  young  and  in  the  old,  and  paralysis  is 
frequently  absent,  though  it  may  be  general.*  Ventricular  hem- 
orrhage is  more  often  secondary  than  primary,  the  blood  having 
torn  its  way  into  the  cavity. 

Hemorrhage  limited  to  the  thalamus  gives  rise  to  markedly  in- 
creased temperature  of  the  palsied  side,  but  exhibits,  even  when  on 
the  left  side,  no  aphasia,  as  we  are  apt  to  find  in  affections  in  and 
around  the  left  corpus  striatum.  The  palsy  is  comparatively  slight. 
Sensory  svmptoms  are  not  uncommon,  but  there  are  no  vaso-motor 
symptoms.  A  large  bleeding  into  the  anterior  lobe  deprives  the 
patient  of  the  sense  of  smell  on  the  side  on  which  it  has  happened. 

Hemorrhage  into  the  corpora  quadrigemina  presents  most  fre- 
quently this  combination  of  symptoms:  muscular  tremblings, 
convulsions,  impairment  of  sight  and  alteration  of  the  pupils. 
Cerebellar  hemorrhage  gives  rise  to  very  temporary  loss  of  con- 
sciousness; to  relaxation  of  the  muscles  of  the  limbs  without 
paralysis  or  impaired  sensibility ;  and  to  frequent  vomiting ; 
vision  is  not  affected.  In  instances  in  which  there  is  hemiplegia 
it  may  or  may  not  be  on  the  same  side  as  the  lesion.  In  hemor- 
rhage into  one-half  of  the  pons,  there  is  palsy  of  the  extremities 
on  one  side,  and  of  the  face  on  the  other. f  There  may  also  be 
hyperresthesia  in  some  parts  of  the  body,  and  amaurosis. |     In 


*  Sanders,  Amer.  Journ.  Med.  Sci.,  July,  1881. 
t  Gubler,  Gaz.  Hebdom.,  1858,  1859. 
X  Brown-Sequard. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COUD.  ]  77 

lesions  of  the  pons,  too,  as  in  those  of  the  medulla,  we  have  high 
and  rapidly  rising  temperature  almost  from  the  onset,  and  we  find 
an  exception  to  the  rule  that  the  lateral  deviation  of  the  eyes  and 
head,  a  sign  so  commonly  present  in  apoplexy,  is  toward  tlie  side 
of  the  brain  affection.*  Anaesthesia  and  double-sided  palsy  are 
often  met  with,  and  initial  convulsions  are  very  common,  and 
are  sometimes  limited  to  the  legs.  There  is  vomiting,  as  well  as 
hyperpyrexia. 

In  cortical  bleedings  we  are  apt  to  have  localized  convulsions 
and  but  slight  palsy.  Hemorrhage  limited  to  the  arachnoid, 
with  the  blood  poured  into  the  subarachnoid  spaces,  occasions 
ordinarily  j^ain  in  the  head,  somnolency,  and  profound  coma 
without  paralysis,  and  without  anaesthesia  or  slow  pulse,  but  with 
relaxation  of  the  muscles,  and  sometimes  with  convulsions ;  now 
and  then  the  symptoms  assume,  to  all  appearance,  a  remittent 
course.  It  is  a  very  fatal  form  of  apoplexy,  occurring  chiefly  in 
new-born  children,  and  after  injuries  to  the  head,  or  from  the 
giving  way  of  a  diseased  and  widened  artery,  or  in  consequence 
of  a  rupture  of  one  of  the  sinuses  of  the  dura  mater. 

When  the  effusion  of  blood  takes  place  between  the  dura  mater 
and  the  arachnoid,  it  is,  as  Virchow  has  proved,  generally  the 
ultimate  result  of  an  inflammation  and  of  subsequent  changes  of 
the  inner  surface  of  the  dura  mater.  On  close  inquiry,  the  pre- 
cursory symptoms  of  a  disease  of  the  membrane  may,  perhaps, 
be  traced  by  the  constant  and  localized  pain,  and  the  nocturnal 
restlessness.  But  the  symptoms  of  the  hsematoma  are  as  obscure 
as  its  pathology ;  indeed,  by  some,  by  Huguenin  f  especially,  the 
affection  is  looked  upon  as  originally  a  hemorrhage  from  rupture 
of  the  veins  on  the  brain-surface.  It  happens  generally  after  fifty 
years  of  age,  in  the  decrepit  or  in  those  suffering  from  pernicious 
anjemia,  scurvy,  emphysema,  hooping-cough,  alcoholism,  or  after 
head-injuries.  When  the  cyst  ruptures  in  the  thickened  mem- 
brane, which  it  may  not  do  for  years,  the  signs  are  those  of  an 
apoplectic  condition,  lasting  for  eight  or  ten  days. 

What  has  been  said  of  the  symptoms  pointing  to  the  seat  of 
lesion  is  exclusively  based  on   well-attested  clinical  experience. 


*  Bastian,  Paralysis  from  Brain  Disease. 
■f  Ziemssen's  Cyclopaedia. 
12 


178  MEDICAL    DIAGNOSIS. 

The  recent  researches  on  the  hjcalization  of  the  cerebral  functions 
promise  to  make  our  knowledge  of  the  seat  of  the  apoplexy  still 
more  definite. 

Let  us  now  examine  how  the  diagnosis  of  apoplexy  can  be  de- 
termined, and  how  this  malady  may  be  distinguished  from  otlicr 
states  which  produce  rapid  loss  of  consciousness,  or  sudden  paral- 
ysis. Not  to  mention  epilepsy, — the  phenomena  of  which  we  shall 
farther  on  contrast  with  those  of  apoplexy,  and  shall  observe  to 
differ  chiefly  in  the  prominence  of  the  convulsive  seizures  ;  or  men- 
ingitis,— in  which  fever,  headache,  and  other  signs  of  an  acute 
cerebral  disease  precede  insensibility  ;  or  a  tumor, — which,  save  in 
the  rarest  instances,  leads  only  very  gradually  to  a  comatose  con- 
dition ;  or  sun-stroke, — exhibiting  insensibility,  yet  also  present- 
ing points  of  contrast  which  will  shortly  engage  our  attention, — 
we  find,  excluding  concussion  and  compression  as  belonging  more 
strictly  to  surgical  diagnosis,  these  morbid  states  liable  to  be  mis- 
taken for  apoplexy  : 

Obstructions  of  the  Cerebral  Arteries  ; 

Insensibility  fro^i  Drink,  or  from  Narcotic  Poisons  ; 

Uraemia  ; 

Diabetic  Coma  ; 

Syncope ; 

Asphyxia  ; 

Acute  Softening; 

Sudden  Extensive  Paralysis  ; 

Protracted  Sleep  ; 

Cerebral  Hysteria. 

Ohsf ructions  of  the  Cerebral  Arteries. — Cerebral  embolism  or  cer- 
ebral thrombosis  will  produce  symptoms  so  similar  to  hemorrhage 
that  in  every  case  of  apoplexy  we  must  ask  ourselves  the  question 
whether  the  coma  be  due  to  obstruction  of  the  vessels  or  their 
rupture.  We  may  suspect  that  an  arterial  obstruction  is  the  cause 
of  the  cerebral  embolism  if  the  patient  be  young  or  in  middle 
life;  or  if  he  be  laboring  under  an  acute  or  a  subacute  endocardial 
inflammation,  or  a  chronic  valvular  affection  in  which  fragments 
of  vegetations  may  be  broken  off  and  washed  into  the  vessels  of 
the  brain ;  or  if  within  a  brief  period  several  incomplete  attacks 
have  occurred  before  a  ])erfect  comatose  condition  sets  in.  The 
usual  locality  of  the  impaction  is  in  the  middle  cerebral  artery ; 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  ]  70 

and  the  consequences  of  the  interrupted  circulation  are  at  once 
perceived  in  the  adjacent  centre  of  motion, — the  corpus  striatum. 
The  palsy  which  ensues  in  connection  with  the  apparently  apo- 
plectic phenomena  is,  with  rare  exceptions,  one-sided ;  and  the 
.facial  paralysis  is  on  the  same  side  with  the  paralysis  of  the 
limbs.  Unlike  what  happens  in  cerebral  hemorrhage,  little,  if 
any,  fall  of  temperature  occurs,  but  there  are  subsequent  decided 
fever  and  severe  headache,  with  greater  heat  on  the  palsied  side. 
If  the  obstruction  be  in  the  left  middle  cerebral  or  its  branches, 
which  is  more  common  than  on  the  right  side,  aphasia  is  among 
the  symptoms. 

The  hemiplegia  is  not  of  necessity  attended  with  loss  of  con- 
sciousness, or  this  is  slight  and  of  short  duration;  sometimes 
giddiness  and  incoherence  take  the  place  of  unconsciousness ;  con- 
vulsions are  not  infrequent.  The  palsy  is  often  quickly  followed 
by  gangrene  of  the  extremities,  or  it  is  associated  with  disturbance 
of  the  kidneys,  or  with  enlargement  of  the  spleen  and  tenderness 
in  the  splenic  region,  due  to  changes  in  the  organs,  produced  by 
an  impaction  of  fibrin,  if  plugs  be  washed  also  into  other  arteries 
of  the  body.  Just  as  in  apoplexy,  we  find  in  obstructions  of  the 
vessels,  softening  as  a  result  of  the  accident ;  and  the  symptoms 
of  this  secjuel  are  not  different  from  what  they  are  in  any  form  of 
the  lesion.    Monoplegias  are  more  frequent  than  after  hemorrhage. 

Occasionally  the  clot  is  not  washed  into  the  brain,  but  is  formed 
in  one  of  its  arteries.  The  thrombosis  may  extend  thence  as  far 
as  the  common  carotid.  Hasse,  who  has  placed  two  such  cases 
on  record,  mentions  that,  independently  of  the  cerebral  symptoms, 
they  may  be  recognized  by  the  absence  of  pulsation  in  the  carotid 
of  the  affected  side,  and  by  its  tense,  cordy  feel.*  The  plugging 
of  the  carotid  may  produce  apoplexy  with  passing  hemiplegia, 
or,  as  in  an  instance  mentioned  by  Penzoldt,t  sudden  blindness. 
Thrombosis,  as  we  ordinarily  see  it,  occurs,  like  apoplexy,  in  elderly 
persons,  and,  though  it  may  be  sudden,  is  not  apt  to  be ;  there  are 
warnings  of  the  attack,  persistent  headache,  and  the  signs  of  a 
weak  heart ;  and  the  coma  is  rarely  as  profound  as  in  apoplexy. 
Thrombosis  is  caused  by  atheroma,  by  syphilitic  disease  of  the 

*  Zeitschr.  fur  Eation.  Pathol.,  Band  iv. 

f  Deutsches  Archiv  fiir  Klin.  Med.,  Dec.  1880. 


180  MEDICAL    DIAGNOSIS. 

arteries, , or  bv  blood-change  Sy])liilitic-  thrombosis  is  seen  chieflv 
at  a  comparatively  early  age,  and  is  often  funnd  to  be  combined 
Avith  peripheral  paralysis  of  one  of  the  cranial  nerves.  In 
thrombosis  of  the  basilar  artery  the  symptoms  are  like  those 
of  tumor  of  the  l)rain  ;  epileptiform  attacks  and  choked  disks 
are  met  with,  as  well  as  often  high  temperature  and  alternate 
hemiplegia.* 

Insensibilifif  from  Drink,  or  from  Narcotic  Po/son.s-. — Both  these 
conditions  are  sometimes  very  difficult  to  distinguish  from  tlie 
coma  of  apoplexy;  and,  if  we  are  not  cognizant  of  the  circum- 
stances preceding  their  development,  Ave  have  only  these  points  to 
guide  us :  in  intoxication  there  is  a  strong  smell  of  whiskey,  gin, 
or  whatever  liquor  has  produced  it,  emanating  from  the  mouth, 
and  alcohol  may  be  detected  in  the  urine,  points  which  would  be 
conclusive  were  it  not  that  apoplexy  may  come  on  in  the  drunken 
state ;  and  the  man,  although  unconscious,  is  not  often  entirely  be- 
reft of  all  power  of  motion, — he  is  certainly  not  paralyzed.  ]\Iore- 
over,  the  pulse  is  not  slow,  it  is  frequent ;  the  pupils  are  gener- 
ally dilated  ;  the  eye  is  injected,  shows  no  lateral  deviation  ;  there  is 
often  violent  struggling,  and  the  symptoms  become  suddenly  much 
ameliorated  after  the  inhalation  of  ammonia,  or  after  the  stomach 
has  been  emptied  of  its  contents.  In  narcotic  poisoning,  espe- 
cially if  from  opium,  the  pupils  are  very  much  contracted,  and  we 
are  likely  to  encounter  repeated  vomiting,  and  a  gradual  intensifi- 
cation of  the  coma.  The  patient,  however,  unless  death  be  close 
at  hand,  can  be  momentarily  roused  from  his  deep  sleep ;  and 
his  calm,  slow  breathing  is  unlike  the  stertor  of  apoplexy.  But 
Avhen  the  hemorrhage  has  taken  place  into  the  pons  A'^arolii, 
the  diagnosis  is  very  difficult,  especially  if  the  bleeding  be  exten- 
sive, for  then  we  are  apt  to  have  a  contraction  of  both  pupils, 
and  the  respiration  may  not  be  stertorous ;  nor  is  there  always 
at  first  paralysis.  Yet  this  subsequently  appears,  and  thus  the 
detection  of  the  cause  of  the  insensibility  is  rendered  easier.f  A 
symptom  of  great  diagnostic  significance,  too,  is  the  occurrence  of 


*  Leyden,  Zeitschr.  f.  Klin.  Med.,  v.,  1882,  quoted  in  Schmidt's  .Jahrlj., 
No.  3,  1883. 

f  See  an  interesting  case  mentioned  by  Hughlings  Jackson  in  London  Hos- 
pital Eoports,  vol.  i.,  1864. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COKD.  181 

convulsions.     Still,  as  Russell  Reynolds  shows,  this  may  happen 
in  opium  poisoning,  and  is  not  very  rare  in  ehildren. 

Nitrobenzole,  which  operates  as  a  narcotic  poison  in  vapor  as 
well  as  in  a  liquid  state,  may,  in  rapidly  fatal  cases,  produce  coma, 
which  may  be  mistaken  for  the  insensibility  of  apoplexy.  But  the 
poison  leads  quickly  to  death  when  coma  has  been  induced,  and  is 
detected  by  its  strong  odor,  resembling  that  of  bitter  almonds.* 
Poisoning  by  drinking  chloroform  gives  rise  to  many  of  the  symp- 
toms of  apoplexy  ;  it  is  discerned  by  the  odor  of  the  breath,  by  the 
quick  and  tumultuons  action  of  the  heart  which  accompanies  the 
stertorous  breathing,  by  the  relaxation  of  the  limbs,  by  the  death- 
like aspect  of  the  face,  by  the  widely-dilated  pupils,  and  by  the 
complete  general  an?esthesia.t  Chloral  insensibility  is  often  pre- 
ceded by  vertigo  and  pains  in  the  legs  and  arms,  and  is  attended 
by  flushing  of  the  face,  injected  conjunctiva,  a  weak  intermittent 
heart ;  the  pnlse  may,  however,  be  slow  and  full.  Hydrocyanic 
acid  poisoning  produces  profound  insensibility,  often  attended  by 
convulsions,  and  by  peculiar  breathing,  short  inspirations,  with 
labored,  prolonged  expiration.  The  breath  has  the  characteristic 
odor  of  the  acid. 

Ursemia. — The  strong  point  in  the  diagnosis  is  that  the  coma 
is  preceded  by  convulsioos.  The  exceptional  instances  are  few 
indeed.  An  examination  of  the  urine  adds,  of  course,  to  certainty ; 
but,  for  obvious  reasons,  it  cannot  always  aid  us  at  once.  More- 
over, albumen — not,  however,  in  large  amounts — may  occur  in 
the  urine  after  an  apoplectic  stroke  and  after  convulsions  not 
uremic.  Puffy  eyelids  and  swollen  ankles,  coma  not  profound, 
peculiar  stertor  seeming  to  emanate  from  the  mouth,  pupils  nor- 
mal or  dilated,  but  equal,  very  low  body  heat,  not  rising  even  as 
the  ease  lasts,  are  symptoms  that  belong  to  ursemic  coma.  Yet 
there  are  cases  of  ursemic  coma  with  high  temperature,  especially 
when  tested  in  the  rectum, J  Unilateral  convulsions  or  loss  of 
power  are  indicative  of  cerebral  mischief  and  tell  against  ureemia. 

Diabetic  Coma. — We  meet  at  times  with  comatose  symptoms 
in  diabetes  which  simulate  those  of  apoplexy,  and  which  are  apt 


*  Taylor,  Guy's  Hospital  Reports,  vol.  x.,  3d  Series. 

f  As  in  the  case  reported  in  L'Union  Medicale,  October,  1864. 

J  McBride,  American  Journal  of  Neurology,  etc.,  1883. 


182  MEDICAL    DIAGNOSIS. 

to.be  connected  with  the  so-called  "  acetunuria,"  or  the  poisoning 
that  takes  place  in  the  organism  from  the  ibrmation  of  acetone. 
Farther  on  we  shall  inqnire  into  the  tests  for  this  substance.  But 
it  may  here  be  stated  that  the  diabetic  coma  produced  generally 
begins  not  abruptly,  but  with  somnolency,  Avhich  })asses  into  coma  ; 
that  it  is  often  preceded  by  great  op[)ression,  and  is  attended  with 
a  rapid  weak  pulse,  but  not  with  hcmi])l('gia  or  other  local  palsies. 

Si/ncojjc — Asjjhijxia. — The  loss  of  consciousness  in  either  of 
these  states  is  as  striking  as  in  apoplexy.  Jjut  there  is  this  de- 
cided difference:  the  suspension  of  thought  and  of  v(tlition  in  a 
fainting-fit  is  due  to  failure  of  the  circulation  :  hence  the  pulse  is 
hardly  or  not  at  all  felt,  instead  of  being  full,  as  it  is  in  apoplexy. 
Further,  the  pallor  of  the  face,  the  quiet  or  sighing  respiration, 
the  well-preserved  reflexes,  and  the  short  duration  of  the  syncope 
mark  plainly  the  one  affection  from  the  other.  And  with  refer- 
ence to  asphyxia,  the  turgid  and  livid  face,  the  bluish  lip,  the 
distressed  and  embarrassed  breathing  preceding  the  convulsions, 
and  the  loss  of  consciousness,  show  clearly  that  the  disturbance 
affects  primarily  the  lungs,  and  does  not  reside  in  the  brain. 

Acute  Softening. — This  may  give  rise  to  symptoms  so  similar  to 
those  of  cerebral  hemorrhage  that  a  differential  diagnosis  is  impos- 
sible. Especially  does  this  happen  if  tlie  disease  manifest  itself 
suddenly,  Avhich,  according  to  Rostan,  occurs  in  one-half  of  the 
cases.  In  those  of  more  gradual  origin,  a  feeling  of  numbness, 
deterioration  of  memory,  irritability  of  temper,  slight  impair- 
ment of  motion,  and  a  vacant,  dull  look,  are  noticed  for  some 
time  before  the  attack.  Occasionally  delirium  immediately  j^re- 
cedes  the  loss  of  consciousness.  jS^ow,  this  may  be  perfect,  or 
imperfect,  or  even  wholly  wanting, — for  the  patient  may  become 
paralyzed,  after  being  merely  confused  or  feeling  distressed,  but 
without  losing  his  consciousness.  The  palsy  is  at  times  attended 
with  hyper£esthesia  and  Avith  rigidity  of  the  limbs ;  some  disorder 
of  sensation  or  some  muscular  twitching  is  almost  always  present. 
And  in  the  recognition  of  acute  softening  we  must  always  bear  in 
mind  its  close  association  with  arterial  or  venous  occlusions,  and 
look  out  for  their  manifestations. 

But  it  is  by  the  after-symptoms  that  we  most  easily  separate 
acute  softening  from  apoplexy.  In  the  latter,  after  the  shock  is 
over,  except  the  attack  be  overwhelming,  a  gradual  improvement 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COHD.  183 

takes  place,  very  obvious  as  regards  the  mental  faculties  and  the 
power  of  articulation  ;  in  the  former,  the  mind  remains  obtuse,  or 
greatly  impaired,  and  there  is  otherwise  but  slight  amelioration  ; 
defects  of  sensibility  are  particularly  noticed,  and  the  paralysis  is 
apt  to  be  irregular  and  more  limited  than  in  apoplexy.  A  signifi- 
cant sign,  too,  of  acute  softening  is  an  increased  secretion  from  the 
mouth  and  eye.* 

Sudden  Extensive  Paralysis  without  Coma. — This  is  not  a  trait 
of  apoplexy,  but  rather  of  occlusion  of  the  large  vessels.  Sudden 
extensive  paralysis  without  coma  is  ordinarily  owing  to  softening 
of  the  brain,  most  apt  to  have  followed  this  occlusion  ;  but  it  may 
be  due  to  hemorrhage  into  the  spinal  column.  Palsy  from  this 
source,  unlike  that  caused  by  cerebral  hemorrhage,  is  almost  in- 
variably double-sided,  is  accompanied  by  severe  spinal  pain,  and, 
if  the  extravasation  have  taken  jilace  into  the  spinal  meninges,  by 
tonic  spasms,  like  those  of  tetanus. 

Protracted  Sleep. — While  recovering  from  acute  diseases,  the 
sick  often  sleep  profoundly  and  for  a  long  time.  Yet  there  is 
little  likelihood  of  confounding  this  with  the  sleep  of  apoplexy  ; 
for  the  antecedent  circumstances  reveal  the  meaning  of  this  resto- 
ration of  nature.  Sometimes,  however,  persons  sink  into  a  deep 
and  prolonged  slumber  without  any  previous  ailment.  Medical 
literature  furnishes  a  number  of  such  instances.  In  one  recorded 
by  Cousins, t  the  tendency  to  somnolency  lasted  for  years.  The 
patient  frequently  slept  three,  and  sometimes  five,  days  at  a  time. 
When  he  awoke  he  was  well.  In  a  case  which  I  saw  with 
Dr.  AVeir  Mitchell, J  the  slumberer  was  aroused  out  of  her  trance 
several  times  by  the  exciting  influence  of  electricity ;  but  this 
finally  lost  its  effect,  and  she  relapsed  into  a  sleep  from  which  she 
awoke  no  more.  These  cases  may  give  the  impression  of  apoplexy, 
yet  they  do  not  resemble  it  strictly.  They  are  unlike  it  in  the 
gentle,  noiseless  breathing ;  in  the  feeble  pulse  ;  in  the  occasional 
motion  of  the  body  ;  and  in  the  protracted  unconsciousness.  Then 
generally  the  patient  can  be  roused  sufficiently  to  take  food.    Pro- 


*  Durand  Fardel,  Maladies  des  Vieillards. 

t  Medical  Times  and  Gazette,  April,  1863.  See  also  a  somewhat  similar 
case.  New  York  Medical  Journal,  Dec.  1867. 

X  Described  by  him,  Transactions  of  College  of  Physicians  of  Philadelphia, 
1856. 


184  MEDICAL   DIAGNOSIS, 

loni!;ed  somnolence  is  also  among  the  marked  symptoms  of  cere- 
bral syphilis.*  In  some  instances  the  disorder  shows  itself  in  a 
constant  tendency  to  fall  asleej)  for  brief  periods  at  a  time.  One 
patient  I  had  slept  repeatedly  during  the  day  about  five  minutes 
at  a  time  on  her  feet.  She  could  be  roused  by  strong  eiforts. 
The  comparatively  short  duration  of  the  spells  of  sleep,  and  the 
absence  of  evidences  of  hysteria  usual  in  trances,  distinguish  these 
cases  of  mtrcolcpi^y  from  trance.  The  recurrence  of  the  slee])v  fits, 
their  innocuousness,  and  the  absence  of  progressive  emaciation 
and  of  enlargement  of  the  cervical  glands  distinguish  narcolepsy 
from  the  dangerous  sleeping  sickness  affecting  negroes  on  the 
west  coast  of  Africa. 

Cerebral  Hyskrid. — The  actual  similitude  and  the  points  of 
contrast  between  this  curious  state  and  apoplexy  may  be  learned 
from  the  following  sketch  : 

A  married  lady,  of  a  remarkably  impressionable  and  nervous 
disposition,  had  been  for  many  months  suffering  from  amenor- 
rhea and  from  sluggish  action  of  the  bowels.  She  had  also  a 
constant  cough,  dependent  upon  tubercles  in  one  of  the  lungs. 
She  had  been  in  very  bad  health,  but  by  the  steady  employment 
of  tonics,  and  the  beneficial  effects  of  a  sea-voyage,  her  symptoms 
were  much  amended.  She  began  to  gain  flesh,  and  to  take  ex- 
ercise without  fatigue.  She  was,  however,  troubled  with  head- 
ache, and  with  pain  at  the  lower  part  of  the  abdomen.  On  one 
occasion  in  the  evening  I  ordered  iier  some  cathartic  medicine ; 
and  in  the  morning  she  was  better  than  usual,  and  in  the  liveliest 
spirits.  A  few  hours  afterward,  I  was  sent  for,  and  found  her  in- 
sensible. She  had  complained  of  a  sudden,  sharp  cramp  near  the 
umbilicus,  and  had  then  ceased  to  speak.  She  remained  uncon- 
scious for  about  twelve  hours ;  yet  not  wholly  so,  for  every  now 
and  then  she  opened  her  eyelids,  muttered  a  Avord  or  two,  a  pleas- 
ant smile  flitted  over  her  countenance,  but  she  soon  relapsed  into 
her  deep  slumber.  Her  thumbs  were  drawn  inward  ;  she  had 
occasional  convulsive  movements ;  the  breathing  was  rapid,  but 
not  noisy ;  the  pulse  feeble, — at  first  slow,  then  frequent ;  her 
eyes  squinted  in  the  most  decided  manner.     Stimulants  and  anti- 


*  See  cases  in  Lecture  XVI.,  Buzzard  on  Diseases  of  the  Nervous  System, 
1882. 


DISEASES    OF   THE    BRAIN    AND    SPINAL    CORD.  185 

spasraodics  were  freely  given,  but  without  much  l)cnefit,  for  she 
recovered  from  her  lethargy  only  with  the  setting  in  of  the  most 
violent  paroxysmal  pains  in  the  abdomen,  shooting  down  the 
thigh,  and  accompanied  by  contractions  of  the  muscles  and  by 
exquisite  local  tenderness.  The  next  day,  without  much  a])ate- 
ment  of  the  suffering,  she  was  perfectly  conscious  ;  but  still  she  had 
an  internal  sfpiint, — nay,  was  totally  blind,  and  remained  so  for 
two  days.  During  this  time  a  menstrual  discharge  began,  which 
in  part  relieved  the  abdominal  pain.  It  is  needless  to  point  out 
how  this  display  of  hysteria  differed  from  apoplexy. 

Aphasia. — In  consequence  of  apoplexy,  and  of  the  morbid 
processes  with  which  it  is  associated  or  to  which  it  leads,  we 
often  see  affections  of  speech,  and  one  in  particular, — aphasia. 
Though  this  is  really  a  mere  symptom,  it  is  so  prominent  as  seem- 
ingly to  constitute  the  disorder.  By  aphasia  is  meant  loss  of  the 
faculty  of  expression  of  thought,  in  consequence  of  loss  either  of  the 
faculty  of  speech,  or  of  that  of  communicating  thought  by  writing 
or  by  gestures.  The  patient  may  be  deprived  of  the  ability  of  ex- 
pressing himself  in  one  of  these  ways,  or  in  all.  Tlie  loss  of  speech 
is  the  most  common,  and  is  apt  to  be  associated  with  a  very  decided 
impairment  of  memory  and  an  enfeeblement  of  intelligence.  The 
disorder  may  be  temporary,  lasting  but  a  few  hours  or  some  days, 
or  it  may  continue  for  months  or  years.  During  its  course  the 
affected  person  is  incapable  of  recalling  words  to  give  utterance  to 
his  ideas ;  or,  if  he  can  recall  the  words  to  the  mind,  and  thus 
think,  he  cannot  express  them. 

Very  often  the  patient  has  but  a  few  M'ords  at  his  control ;  he 
says  "yes"  or  "no"  for  everything,  and  appears  angry  that  he  can 
say  no  more ;  or  he  uses  wrong  words,  knowing  perhaps  that  they 
are  wrong,  and  sometimes  only  those  of  a  profane  kind ;  or  he 
confuses  merely  some  syllables  in  the  words  he  employs ;  or  he 
may  not  be  able  to  utter  a  word,  using  altogether  unintelligible 
expressions.  Yet,  while  in  this  condition,  there  is  no  defect  in 
the  tongue,  or  lips,  or  palate,  to  account  for  the  inability  to  talk ; 
they  are  as  healthy  as  usual ;  the  act  of  swallowing  is  easily  per- 
formed ;  and  even  where  the  aphasia  is  complicated  with  hemi- 
plegia, it  is  not  difficult  to  discern  that  the  imperfect  articulation 
and  thick  s])eech  attending  the  palsy — which,  moreover,  are  apt  to 
pass  off  within  a  short  period  after  the  seizure — are  not  the  cause 


186  MEDICAL   DIAGNOSIS. 

of  the  siiiiiular  disturbance  of  expression;  a  disturbance  Avhich 
will  mostly  show  itself  not  simply  by  tlic  failure  to  utter  words, 
but  also  by  the  inability  to  recollect  them  and  write  them  down. 
Indeed,  it  is  necessary  to  bear  in  mind  that,  while  these  states  may 
coexist,  they  also  may  be  present  separately,  Thus,  there  are  per- 
sons who  can  think,  but  cannot  speak  or  write  ;  there  are  those 
who  can  think  and  write,  but  cannot  speak  ;  and  there  are  those 
who  can  think  and  speak,  but  cannot  write  or  read.  For  the 
second  o-roup  the  term  "  apheniia"  has  been  proposed  ;  for  the 
third,  the  term  "agraphia;"  for  the  fourth,  ''alexia."  Most  pa- 
tients understand  perfectly  well  what  is  said  to  them  ;  some  can 
read  to  themselves  ;  and,  unless  the  general  intelligence  be  percep- 
tibly att'cfted,  they  can  ex})ress  themselves  by  signs  and  gestures. 
In  some  cases  there  is  rather  loss  of  memory,  and  forgetfulness 
and  confusion,  and  perhaps  a  consequent  use  of  wrong  words  ;  but 
when  prompted  the  word  is  at  once  spoken.  Where  the  power  of 
expression  only  is  lost,  but  the  words  are  still  suggested  by  the 
memory,  the  term  "  ataxic  aphasia"  is  used.  Where  the  memory 
of  words  is  altogether  lost,  it  is  customary  to  speak  of  the  affec- 
tion as  "  amnesic  aphasia."  Again,  there  are  cases  in  which  words 
and  ideas  remain,  but  in  which  the  power  of  forming  correct 
sentences  is  greatly  impaired  or  is  lost.  This  has  been  named 
"  akataphasia."  * 

Slips  of  the  tongue  are  by  no  means  always  to  be  regarded 
as  aphasia,  for  very  often  these  have  a  local  cause,  such  as  a  sore 
tongue  or  lip,  or  a  sharp  tooth  fretting  the  tongue,  producing 
unusual  sensations  in  the  mouth. f 

Aphasia  is  dependent  upon  disease  situated  in  the  frontal  con- 
volutions, and  by  Broca  the  lesion  was  correctly  located  in  the 
seat  of  articulate  language,  in  the  posterior  part  of  the  third 
frontal  convolution  of  the  left  side  of  the  cerebrum.  This  ex- 
j^lains  Avhy  the  hemiplegia  which  may  accompany  aphasia  is 
almost  invariably  right-sided.  But  it  may  be  left-sided,  if  the 
corresponding  parts  of  the  right  hemisphere  have  become  the 
main  centre  of  speech,  as  happens  not  infrequently  in  left-handed 
persons.     It  has  further  been  shown  that  the  disturbance  will  be 


*  Steintlial ;  also  Kussmaul,  in  Ziemssen's  Cyclopfedia. 
t  Orel,  St.  Thomas's  Hospital  Keports,  vol.  iv. 


DISEASES    OF   THE    BRAIN    AND    SPINAL    CORD.  187 

in  the  cortical  substance  of  the  speeeli-centre  or  in  tlie  (X)nducting 
fibres,  according  to  the  form  of  aphasia.  Where  the  memory  of 
words  is  gone,  it  is  in  the  former. 

According  to  the  observations  of  Wernicke,*  there  are  two 
centres  of  speech  :  one  is  in  the  first  temporal  convolution  of  the 
left  side,  from  which  fibres  lead  to  the  other,  in  Broca's  convolu- 
tion ;  the  first  is  the  sensory,  the  second  the  motor  centre.  In 
disease  destroying  the  latter,  or  motor  aphasia,  the  jDatient  un- 
derstands, but  can  speak  but  few  words  or  syllables ;  in  disease 
affecting  the  conducting  fibres,  the  number  of  words  as  well  as 
their  understanding  is  good,  but  words  are  exchanged  and  con- 
fused. When  the  first  left  temporal  convolution  is  the  seat  of 
lesion,  "sensory  aphasia,"  the  words  remain,  though  they  are 
wrongly  used,  and,  often  while  the  hearing  is  good,  speech  fails  to 
convey  any  ideas ;  the  words  are  heard  merely  as  sounds.  In 
total  aphas'a  both  centres  are  implicated.  Where  words  are 
heard,  but  fall  meaningless  on  the  ear,  we  call  the  affection  loorcl- 
deafness,  and  know  that  the  lesion  is  in  the  posterior  half  of  the 
first  temporal  convolution,  which  is  also  the  auditory  centre. 

As  regards  the  exact  lesion,  it  is  very  various.  Aphasia  may 
be  due  to  functional  as  well  as  to  organic  disease.  In  cases  of 
aphasia  of  short  duration  and  without  palsy,  there  is  probably 
merely  congestion ;  in  protracted  cases,  and  those  in  which  we 
find  persisting  hemiplegia,  a  large  clot,  or  softening,  or  abscess,  is 
likely  to  be  present ;  embolism  of  the  middle  cerebral  artery  on 
the  left  side  is  prone  to  be  the  cause  in  cases  which  are  associated 
with  valvular  disease  of  the  heart  and  which  have  come  on  sud- 
denly. Enfeebled  nutrition  will  explain  the  aphasia  which  may 
be  noticed  during  the  convalescence  from  grave  acute  maladies. 
This  form  of  the  complaint  and  that  consequent  upon  congestions 
end  in  more  or  less  rapid  and  generally  perfect  recovery ;  in  the 
other  forms,  usually,  either  no  improvement  follows,  or  only  a 
very  partial  gain  of  words  takes  place.  Occasionally  we  meet 
with  aphasia  in  hysteria  or  in  epilepsy,  or  we  encounter  aphasia 
intimately  connected  with  a  syphilitic  cachexia,t  and  dependent 
most  probably  upon  disease  of  the  arteries. 


*  Lehrbuch  der  Geliirakrankheiten,  1881. 

•f-  See  Clin.  Soc.  Tnuis.,  vol.  iii.,  and  Arch.  Gen.  de  Med.,  Feb.  1871. 


188  MEDICAL   DIAGNOSIS. 

The  suddenness  witli  wliieh  the  attack  may  set  in  will  cause  it 
to  be  mistaken  tor  an  ordiuaiy  apt)i)k'i'tic  seizure.  But  we  may 
find  not  the  least  deficiency  in  motion  in  any  juirt  of  the  body,  and 
■\vell-prcserved  consciousness;  or  the  disorder  may  become  manifest 
subsequent  to  attacks  of  vertigo,  or  to  a  paralytic  stroke  preceded 
or  not  by  the  ordinary  signs  of  an  apoplectic  fit.  Under  these 
circumstances  the  diagnosis  cannot  be  definitely  made  until,  after 
fully-returned  consciousness,  we  have  an  opportunity  of  examining 
the  state  of  the  mind,  and  of  the  tongue  and  the  muscles  concerned 
in  articulation,  remembering  that  if  there  be  merely  difiiculty  in 
articulation  the  case  is  not  one  of  aphasia. 

Suil-stroke. — Persons  ex[)osed  to  the  scorching  rays  of  the 
sun  in  midsummer  often  become  dizzy,  and  fall  to  the  ground 
insensible  :  they  have  had  a  sun-stroke.  The  attack  either  takes 
place  while  the  patient  is  still  exposed  to  the  sun,  or,  in  rarer 
instances,  he  reaches  his  home  with  a  staggering  gait  and  a  suifused 
face,  giddy,  faint,  suffering  from  a  dull,  oppressive  pain  in  the 
head,  having  a  constant  desire  to  micturate,  and  after  some  hours 
becomes  unconscious.  However  the  onset,  the  insensibility  which 
occurs  is  generally  complete,  although  it  may  be  so  but  for  a  few 
minutes.  Associated  with  it  are  a  frequent  pulse,  a  skin  harsh 
and  warm  and  sometimes  very  hot  on  the  forehead,  shallow,  noisy 
breathing,  difficulty  in  swallowing,  contracted  or,  more  generally, 
dilated  pupils,  and  relaxation  of  the  limbs.  Scanty  urine,  de- 
lirium, and  convulsions,  which  may  or  may  not  depend  on  urtemia, 
are  not  uncommon. 

When  we  contrast  these  symptoms  with  those  of  apoplexy,  we 
find  the  following  marks  of  distinction :  the  pulse  is  not  slow  and 
full,  but  frequent  and  often  feeble ;  there  is  more  difficulty  in 
deglutition,  but  a  less  snoring  respiration  ;  the  coma  docs  not  or- 
dinarily remain  as  complete  for  so  great  a  length  of  time,  for  soon 
the  patient  may,  temporarily  at  least,  be  partially  roused  from  his 
deep  sleep ;  and  no  hemiplegia,  no  paralysis,  either  of  the  limbs 
or  of  the  cheek,  occurs.  The  temperature  of  the  body  is  usually 
very  high,  104°  to  109°,  and  not  below  the  normal,  as  it  is  at 
first  in  apoplexy.  The  after-symptoms,  too,  are  different :  in  cere- 
bral hemorrhage,  paralysis  ;  in  sun-stroke,  feebleness  of  movement, 
but  no  paral}-sis.  In  the  former,  no  marked,  persistent  headache ; 
in  the  latter,  headache,  more  or  less  chronic,  always  aggravated  by 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD,  189 

walking  in  the  sun,  and  often  for  months  accompanied  by  signs  of 
an  exhausted  nervous  system,  and  in  some  instances  by  epileptic 
convulsions. 

The  question  with  regard  to  the  discrimination  of  these  morbid 
states  is  one  of  great  practical  value,  as  on  the  conclusion  arrived 
at  depends  our  therapeutic  action ;  and  generally  it  is  readily  de- 
termined by  paying  attention  to  the  variance  in  the  symptoms 
mentioned.  But  it  must  be  confessed  tliat  we  sometimes  meet 
with  ambiguous  cases, — cases  in  which  the  signs  of  nervous  ex- 
haustion produced  by  exposure  to  heat  are  blended  with  those  of 
cerebral  congestion  or  hemorrhage  excited  by  the  same  cause,  and 
in  which,  Avhen  they  terminate  fatally,  the  autopsy  shows  not 
simply  a  changed  blood,  or  pulmonary  congestion,  but  turgescence 
of  the  cerebral  vessels,  or  an  extravasation.  It  may  also  be  difficult 
to  distinguish  between  sun-stroke  and  acute  alcoholism,  particu- 
larly because  those  who  drink  freely  are  veiy  prone  to  the  disease. 
The  chief  distinguishing  trait  is  in  the  high  temperature  of  sun- 
stroke, and  the  normal  or  lowered  temperature  of  alcoholism. 

The  remarks  just  made  refer  to  the  most  common  form  of  sun- 
stroke,— that  attended  with  more  or  less  sudden  loss  of  conscious- 
ness. But  there  are  cases  in  which  the  abnormal  manifestations 
come  on  gradually,  and  in  which  the  patient  at  no  time  becomes 
insensible.  I  have  seen  a  number  of  the  kind  :  they  were  not 
unusual  among  officers  sent  home  from  the  wearing  summer 
campaigns  of  our  late  Avar.  The  chief  symptoms  are  intense 
headache,  nausea,  prostration,  and  inability  to  perform  anv  work 
requiring  sustained  attention.  All  these  signs  appear  after  pro- 
tracted exposure  to  the  sun ;  and  they  mend  but  very  tardily. 
In  truth,  in  the  sloMdy-developed  disorder  the  subsequent  nervous 
exhaustion  and  the  paroxysms  of  headache  seem  to  be  much  more 
persistent  than  the  same  phenomena  following  what  looks  like 
the  more  violent  form  of  the  malady.  Among  the  sequelae  of 
these  apparently  incomplete  attacks  are  irritability  of  the  bladder, 
incontinence  of  urine,  and  irregular  action  of  the  heart.  But 
nothing  is  as  striking  as  the  loss  of  mental  and  bodilv  enerarv. 

The  symptoms  of  "  insolatio,"  or  sun-stroke,  may  be  induced 
by  prolonged  atmospheric  heat,  while  the  patient  is  in-doors  and 
not  exposed  to  the  rays  of  the  sun.  Such  cases  of  heat-stroke  are 
known  to  occur  in  India  even  at  midnight.     They  may  be  pre- 


190  ^[EDICAL    DIACxXOSIS. 

ceded  by  a  sense  of  extreme  weariness,  by  inability  to  sleep,  by  loss 
of  appetite,  by  constipation  and  frequent  micturition,  and  by  de- 
ficient perspiration  ;  or  the  signs  of  exhaustion,  followed  by  more 
or  less  complete  insensibility,  appear  without  distinct  prodromes. 
Cases  of  the  kind  under  consideration  may  or  may  not  show  an 
increased  or  high  temperature.     Generally  they  do. 

Then,  again,  we  find  eases  of  licat  exhaustion,  often  seen  in  our 
hot  summers,  in  which  there  is  from  the  first  great  tendency  to 
syncope;  the  skin  is  pale,  cool,  and  moist,  the  temperature  not 
increased,  tlie  pulse  very  feeble,  the  pupils  dilated,  and  stimulants 
freely  given  rapidly  relieve  the  urgent  symptoms. 

The  nature  of  heat  exhaustion,  as  of  sun-stroke,  is  obscure. 
It  is  held  by  H.  C  Wood*  to  be  a  fever  which  is  dependent 
upon  heat.  Certain  it  is  that  the  heat  centres  are  very  much  dis- 
turbed in  the  affection.  In  occasional  instances  meningitis  rather 
than  sun-stroke  follows  exposure  to  the  sun,  and  we  find  the 
ordinary-  symptoms  of  meningeal  inflammation. 

Catalepsy. — This  is  a  sudden  suspension  of  thought,  of  sen- 
sibility, and  of  voluntary  motion,  during  tlie  continuance  of  which 
the  muscles  become  rigid  and  retain  the  exact  position  they  hap- 
pen to  be  placed  in.  This  uncommon  complaint  occurs  in  parox- 
ysms, which  may  last  but  a  few  minutes  or  for  several  hours,  and 
during  which  tlie  most  complete  anaesthesia,  not  only  of  the  skin, 
but  also  of  the  deeper  tissues,  may  occur.f  Reflex  action  is  abol- 
ished and  the  temperature  is  lowered.  The  disorder  is  met  with 
mainly  in  females,  especially  in  hysterical  females,  and  alternates 
wath  outbreaks  of  hysteria.  But  it  may  also  exist  in  the  male 
sex,  and  be  in  either  hereditary.  It  has  even  been  noticed  as 
an  epidemic  in  localities  where  there  are  many  families  closely 
connected  by  intermarriage.^  Xervous  exhaustion  or  sudden 
alarm  predisposes  to  the  seizures,  which  at  times  recur  periodically 
and  last  from  a  few  minutes  to  a  few  hours. 

Catalepsy  may  be  mistaken  for  apoplexy,  or  even  for  death.  It 
differs  from  apoplexy  by  its  constant  recurrence;  and,  furtlier, 
during  an   attack   the  eyes  are  wide  open,  the  pupils,  although 

*  Thermic  Pever,  or  Sunstroke. 

f  As  in  the  case  reported  by  Lasegue,  Archives  Generales  de  Medecine, 
tome  i.,  1864. 

t  Vogt;  Schmidt's  Jahrbiicher,  Bd.  cxx.  p.  301. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  191 

dilated,  are  very  susceptible  to  light,  and  there  is  an  absence  of 
stertorous  breathing  as  well  as  of  the  characteristic  relaxation  of 
the  muscles  or  of  the  paralysis  of  apoplexy, — for  the  limbs  are 
outstretched,  or  held  in  every  conceivable  annoying  or  painful 
position ;  yet  as  soon  as  consciousness  is  restored,  their  movement 
fully  returns.  The  pulse  is  not  retarded  ;  on  the  contrary,  although 
feeble,  it  becomes  very  frequent. 

The  perplexing  aifection  varies  from  a  kindred  state,  ecstasy,  in 
this  :  in  the  latter  the  loss  of  consciousness  is  not  complete.  The 
patient  is  merely  insensible  to  external  objects,  because  he  is  in- 
tensely absorbed  in  some  vision ,  present  to  his  imagination,  or 
in  the  contemplation  of  some  subject  to  him  of  all-engrossing  in- 
terest. But  he  is  not  statue-like  ;  on  the  contrary,  his  countenance 
is  animated  and  earnest,  and  he  talks,  declaims,  sings. 

There  is  a  curious  form  of  the  disorder,  which  Sir  Thomas 
Watson  describes.  It  is  an  imperfect  kind  of  catalepsy,  called 
daymare,  the  aifected  person  being  incapable  of  moving  or  speak- 
ing, yet  cognizant  of  all  that  goes  on.  These  seizures  of  tem- 
porary deprivation  of  muscular  power,  without  unconsciousness, 
are  thought  to  depend  upon  a  diseased  state  of  the  blood-vessels 
of  the  brain. 

Feigned  catalepsy  may  be  distinguished  from  the  true  disease 
by  the  muscles  quickly  showing  signs  of  fatigue,  which  they  do 
not  in  real  catalepsy.  A  pressure-drum,  Charcot*  found,  fixed 
at  the  extremity  of  the  outstretched  limb  in  a  person  who  feigns 
will  in  a  few  minutes,  in  place  of  the  straight,  regular  line,  show 
crooked,  very  undulating  traces,  and  the  same  irregularity  is  seen 
in  the  tracings  of  the  pneumograph  applied  to  the  chest. 

Catalepsy  may  be  artificially  induced,  as  we  know  from  the 
interesting  experiments  on  "  hypnotism"  w^hich  have  of  late  years 
been  made.  Catalepsies  of  particular  groups  of  muscles,  or  partial 
catalepsies,  can  also  be  artificially  excited. 

Diseases  marked  by  Convulsions  or  Spasms. 

Epilepsy. — Epilepsy  is  a  disease  the  chief  manifestation  of 
which  consists  in  recurring  attacks  of  sudden  loss  of  consciousness, 
attended  with  convulsive  movements.     The  patient  falls  to  the 

*  Third  volume  of  Clinical  Lectures,  1889. 


192  MEDICAL   DIAGNOSIS. 

ground,  without  thought,  without  feeling,  without  the  power  of 
vohuitary  motion.  He  utters  often  a  short  piercing  cry,  then  a 
fearful  struggle  begins.  The  legs  are  stiff,  and  turned  inward  ; 
the  head  is  tossed  backward,  or  from  side  to  side ;  the  mouth  is 
distorted,  the  lijis  are  covered  with  foam ;  the  arms  are  out- 
stretched and  rigid,  or  thrown  about  with  great  force ;  the  eyelids 
are  half  closed ;  the  teeth  are  ground  together,  and  the  tongue  is 
thrust  between  them,  and  often  severely  bitten.  Gradually  the 
convulsive  movements  become  less  violent  and  cease  altogether, 
and  the  patient  passes  into  a  deep  sleep,  from  \vhicli  he  awakes 
fatigued  and  exhausted,  and  dull  in  intellect.  But  these  symp- 
toms disappear,  and  he  returns  to  his  usual  state  of  health. 

Yet  every  paroxysm  does  not  present  the  same  phenomena,  or 
run  the  same  definite  course.  In  many  the  attack  is  preceded  by 
strange  sensations  :  by  a  peculiar  train  of  thought ;  by  retching ; 
by  the  feeling  of  a  puff  of  air  ascending  from  the  extremities  to 
the  head.  This  "  aura  epileptica,"  on  which  so  much  stress  has 
been  laid,  is,  however,  far  from  constant.  But  it  may  exist  with- 
out hardly  being  perceived  :  it  may  be  an  unfelt  irritation  starting 
from  some  peripheral  nerve  in  any  part  of  the  skin,  or  from  some 
organ  not  deeply  seated,  as  the  testicle,  and  its  point  of  departure 
may  be  detected  by  observing,  during  the  fit,  in  Avhat  neighbor- 
hood the  first,  or  the  most  violent,  or  the  most  prolonged  contrac- 
tions occur.  In  very  rare  instances  sudden  spasms  of  the  face 
and  chest  occur,  with  arrest  of  respiration,  and  with  a  subsequent 
clonic  convulsion,  yet  with  so  little  unconsciousness  that  it  re- 
mains doubtful  whether  the  paroxysm  has  been  attended  at  all 
with  unconsciousness. 

Some  seizures  are  very  light, — a  transient  suspension  of  con- 
sciousness, a  slight  twitching  of  some  of  the  muscles,  a  fixed  gaze, 
perhaps  a  decided  impression  of  vertigo,  and  all  is  over.  These 
abortive  fits,  the  petit  mal,  or  minor  attacks,  are  very  apt  to  pre- 
cede by  some  days  a  severe  attack,  or  several  of  them  may  take 
the  place  of  the  more  turbulent  form  of  the  disorder.  And  they, 
like  the  graver  epileptic  convulsion,  may  present  strange  irregu- 
larities. They  may  manifest  themselves,  for  instance,  only  in 
bursts  of  unmeaning  laughter  ;*  or  intellectual  derangement  re- 

*  George  Paget,  British  Medical  Journal,  Feb.  1859. 


DISEASES    OF   THE    BRAIN"    AND    SPINAL    CORD,  193 

places  the  ordinary  convulsive  attack  ;*  or  there  is  mental  wan- 
dering, with  disposition  to  commit  acts  of  violence.  The  attacks 
of  epilepsy  which  are  chiefly  characterized  by  vertigo  are  distin- 
guished from  all  other  forms  of  vertigo  by  the  loss  of  conscious- 
ness they  also  mostly  present,  and  the  absence  of  any  giddiness  in 
the  intervals.  In  nocturnal  epilepsy  ecchymoses  on  the  face,  con- 
junctival extravasations,  a  severe  headache  on  awakening,  and  a 
sore  tongue,  may  indicate  what  has  Iiappened  in  the  night. 

The  epileptic  paroxysm  does  not  always  pass  off  without  leaving 
some  trace  of  the  profound  disturbance  it  has  occasioned.  It 
may  be  followed  by  hemiplegia.  Whether  this  be  due  to  a  con- 
gestion of  the  brain  during  the  fit,  or,  as  Hughlings  Jackson  f 
asserts,  to  exhaustion  of  the  nerve-centres  following  the  excessive 
discharge  of  the  nerve  force  bringing  about  the  convulsion,  it  is 
certain  that  the  palsy  is  very  transient.  Another  sequel  of  the 
attack  is  aphasia ;  another,  loss  of  voice ;  another,  abdominal 
tenderness. 

In  the  intervals  between  the  seizures  the  patient  is  not  in  reality 
well.  His  temper  is  irritable,  and  his  mental  faculties  slowly  but 
certainly  deteriorate.  The  loss  of  memory,  particularly,  is  very 
marked ;  and  dementia  is  not  an  unusual  complication  of  long- 
continued  epilepsy.  In  some  epileptics  there  is  much  mental  ex- 
citement or  a  curious  mental  state  preceding  the  seizures,  or  a 
violent  and  dangerous  mania  following  the  fit.  Again,  as  I  have 
had  occasion  to  note  in  common  with  several  recent  observers,  a 
temporary  albuminuria  is  not  unfrequently  met  with  at  the  ter- 
mination of  the  paroxysm. 

Epilepsy  is  either  central  or  peripheral :  that  is,  the  exciting 
cause  is  seated  in  the  nervous  centres,  most  likely  in  the  cortex  or 
in  the  medulla ;  or  affects  the  peripheral  nerves,  and  is  by  them 
reflected  to  the  centres,  whose  sudden  overaction  determines  the 
paroxysm.  It  is  thus  that  the  malady  originates  in  injuries  of 
nerves,  in  diseases  of  the  skin,  of  the  stomach  and  intestines,  and 
of  the  uterus,  in  the  irritation  of  worms,  or  in  consequence  of 
congenital  phimosis,!  or  of  chronic  nasal  catarrh. §     jSTow,  with 

*  Thorne  on  Masked  Epilepsy,  St.  Bartholomew's  Hosp.  Eep.,  vol.  vi. 
t  After-Effects  of  Epileptic  Discharges,  West  Eiding  Eeports,  1876. 
X  Althaus,  Lancet,  Feb.  1867. 

I  Cases  collected  by  Salinger,  Polyclinic,  June,  1887. 

13 


194  MEDICAL    DIAGNOSIS. 

reference  to  botli  tlie  prognosis  and  the  treatment,  it  is  very  im- 
portant to  diseriminate  between  ej)ilepsy  of  centric  and  epilepsy 
of  eccentric  origin;  and  to  arrive  at  a  conc]usit)n  is  possible  only 
by  a  thorongh  examination  oi'  all  the  constitutional  symptoms, 
and  by  ascertaining-  the  starting-])oint  and  tracing  the  course  of 
the  aura.  The  cases  in  which  tiie  aura  is  interrupted  and  the 
paroxysm  arrested  l)y  a  ligature  are  well  known.  Xothnagel 
cites  an  instance  in  wiiich  the  aura  began  Avith  peculiar  sensations 
in  the  stomach,  and  the  attack  was  stopped  by  swallowing  table- 
salt.  Here  we  have  reflex  causes.  Another  diagnostic  element  of 
great  practical  value  is  to  determine,  after  we  have  concluded  the 
epilepsy  to  be  central,  if  it  be  symptomatic  of  a  cerebral  disorder, 
— such  as  of  a  tumor,  of  cysticerci  lodged  in  the  organ,  of  a 
syphilitic  affection  of  the  membranes,  or  of  a  disturbance  of  the 
brain  produced  by  disease  of  the  skull-cap, — in  fact,  of  any  of 
those  cerebral  maladies  which  are  known  to  engender  epileptic 
seizures;  or  if  it  be  watery  blood,  or  vitiated  blood  full  of  abnor- 
mal ingredients,  as  in  diseases  of  the  kidneys,  acting  injuriously 
on  the  nutrition  of  the  cerebral  texture ;  or  if  it  be  idiopathic, 
due  to  causes  we  do  not  fully  understand,  chief  among  ^^■hicll  is 
probably  a  molecular  change  in  the  cells  of  the  gray  matter  of 
the  cortex.  During  the  paroxysm  it  is  impossible  to  determine 
the  character  of  the  epilepsy ;  but  in  the  interval  ^ve  may  often 
do  so  by  close  attention  to  the  history  of  the  case,  and  by  noting 
whether  the  patient  enjoys  the  usual  health  of  epileptic  subjects, 
or  presents  signs  of  a  chronic  cerebral  disorder.  Romberg  tells 
us  that  where  affections  of  the  bones  of  the  head  lie  at  the  root 
of  the  complaint,  the  fits  are  readily  induced  by  pressure  upon 
the  skull ;  and,  further,  that  if  there  be  disease  residing  in  one  of 
the  cerebral  hemispheres,  the  aura  affects  the  opposite  side  of  the 
bodv,  and  is  generally  confined  to  the  upper  extremity.  Epilepsy 
is  often  found  in  connection  Avith  ear  disease,  and  especially  with 
purulent  otitis.* 

Limited  convulsive  seizures  are  connected  with  disease  of  special 
convolutions  ;  and,  as  Hughlings  Jackson  f  has  shown,  if  we  have 
a  convulsion  which   is  limited,  or  at  least  begins  always  in  the 


*  Ormerod,  Brain,  April,  1883. 

t  Medical  Times  and  Gazette,  1875. 


DISEASES    OP    THE    BRAIN    AND    SPINAL    CORD.  195 

same  limited  manner,  either  a  tonic  or  a  clonic  spasm  of  a  group 
of  muscles,  we  may  from  this  monospasm  diagnosticate  an  irrita- 
tive lesion  in  the  motor  centre  presiding  over  the  disturbed  part, 
though  in  the  hemisphere  opposite  to  the  spasm.  Tlie  irritative 
lesion  is  most  frequently  a  meningo-encephalitis ;  the  centre  in- 
volved becomes  highly  charged,  a  discharge  takes  place  with  the 
convulsion,  and  a  temporary  paralysis  in  the  affected  group  of 
muscles  results.  The  spasm  most  frequently  originates  in  the 
hand.  At  first  there  is  no  loss  of  consciousness  during  the 
seizures,  but  as  the  spasms  spread  and  become  nnilateral,  con- 
sciousness is  lost.  Syphilitic  epilepsy  is,  for  the  most  part,  of  the 
kind  of  epilepsy  just  described,  Jacksonian  epilepsy. 

Much  has  been  said  of  the  distinction  between  epilepsy  and 
convulsions.  Now,  as  regards  the  seizure  itself,  there  is  no  appre- 
ciable difference :  the  only  diversity  consists  in  the  recurrence  of 
the  attack  after  intervals  of  comparative  health,  and  in  the  non- 
existence of  any  disturbance  from  which  convulsions  are  likely  to 
arise,  such  as  a  recent  injury  to  the  head,  an  eruptive  fever,  the 
parturient  state,  inflammation  of  the  brain,  a  Bright's  kidney, 
teething,  or  rickets.  In  children,  who,  as  is  well  known,  are 
particularly  subject  to  convulsions,  the  diagnosis  may  be  a  diffi- 
cult matter ;  but  the  fits  of  epilepsy  are  distinguishable  by  the 
dulness  of  intellect,  and  the  slow  mental  and  bodily  development, 
observable  in  the  intervals.  And  we  are  not  often  called  upon 
to  make  this  differential  diagnosis,  because  of  the  extreme  rarity 
with  which  epilepsy  occurs  in  the  young ;  although  many  insist 
that  it  is  more  frequent  than  is  supposed,  basing  this  assump- 
tion on  the  generally-received  fact  that  the  history  of  epileptics 
shows  them  to  have  suffered  greatly  from  convulsions  during 
childhood. 

The  diseases  which  are  most  apt  to  be  confounded  with  epilepsy 
are  hysteria  and  apoplexy.  The  former — like  all  the  rest  of  the 
group  now  under  discussion,  like  chorea,  like  tetanus,  like  hydro- 
phoJbia — is  discriminated  by  the  absence  of  that  perfect  suspension 
of  consciousness  that  takes  place  in  epileptic  seizures ;  and  there 
are  other  marks  of  distinction,  to  which  we  shall  presently  refer. 
In  apoplexy,  as  in  epilepsy,  we  meet  with  loss  of  consciousness, 
sometimes  with  convulsions.  But  these  are,  on  the  whole,  rare, 
and  coma  precedes  and  does  not  follow  them,  as  happens  in  epi- 


196  MEDICAL    DIAGNOSIS. 

lopsy.  Then,  stertorous  breathing,  and  a  slow,  i'nll  pulse,  are  not 
observed  in  epilepsy  ;  for  the  breathing,  although  irregular  and 
gasping,  is  not  eoarse  and  noisy,  and  the  ])ulse  is  ieeble,  irregular, 
and  frequent.  .Epileptie  patients  bite  their  tongue  ;  this  does  not 
oeeur  in  apoplexy.  In  epilepsy  the  paroxysm  seldom  lasts  longer 
than  from  ten  to  tifteen  minutes  before  eonseiousness  returns 
and  before  the  convulsions  cease ;  in  apoplexy  the  insensibility  is 
of  much  longer  duration.  Epilepsy  is  not  usually  followed  by 
])aralysis  ;  apoplexy  is  commonly. 

Epilepsy  is  often  feigned ;  yet  impostors  cannot  feign  it  com- 
pletely. They  may  bite  their  tongue  ;  they  may  imitate  the  stertor, 
the  foam  at  the  mouth,  the  convulsions,  the  thumb  drawn  in- 
ward toward  the  palm,  the  confused  air  on  awakening;  they  may 
simulate,  although  they  rarely  do  so,  the  indittcrence  to  pain  ;  yet 
there  is  one  feature  of  the  real  attack  they  cannot  copy, — the  in- 
sensil)ility  of  the  iris.  No  matter  how  skilful  the  dissembler,  his 
pupils  must  contract  when  exposed  to  a  strong  light,  they  must 
dilate  when  the  stimulus  is  withdrawn.  Unfortunately,  there  are 
several  difficulties  in  making  this  test  an  alxsolute  one.  In  the 
first  place,  the  pupils,  during  a  fit,  cannot  always  be  readily  ob- 
served. In  the  second  place,  not  in  every  case  of  epilepsy  are 
they  perfectly  immovable  ;  in  some,  though  sluggish,  they  react 
to  light.  Again,  as  proved  by  Keen,  violent  muscular  motion 
instantly  dilates  the  pupil,  and  so  long  as  the  movement  continues, 
so  long  will  the  iris  act  sluggishly,  even  when  exposed  to  a  bright 
light.  Thus,  muscular  spasms  alone,  even  when  sinudated,  may 
cause  the  pupils  to  be  dilated  and  inactive.  A  test  said  to  be 
more  generally  useful  is  the  administration  of  ether.  AVhen  given 
to  an  epileptic,  its  first  effect  is  to  increase  the  violence  of  the 
spasm,  but  eventually  the  patient  passes  into  the  deep  sleep  pro- 
duced by  ether,  without  any  of  the  prior  cerebral  excitement ;  while 
in  the  malingerer  this  manifests  itself  by  talking  and  laughing, — 
in  fact,  in  the  usual  way.* 

Chorea. — This  spasmodic  aflPection  is  chiefly  met  with  in  yo*nig 
persons,  especially  in  girls  approaching  the  age  of  puberty.  It 
is  characterized  by  irregular  clonic  sjiasms  of  groups  of  muscles 
under  the  influence  of  the  will,  and  mainly  of  those  on  one  side  of 


*  Keen,  Mitchell,  and  Morehouse,  Amer.  Journ.  Med.  Sci.,  Oct.  18G-4. 


DISEASES    OF   THE    BRAIN    AND   SPINAL    CORD.  197 

the  body.  But  the  patient  is  not  deprived  of  consciousness  and 
of  all  power  of  voluntary  motion.  He  knows  what  he  is  about, 
and  can  in  part  executej^the  movements  he  undertakes;  yet  his 
limbs  are  not  completely  under  his  control.  They  obey  only  his 
general  directions,  but  not  entirely  or  at  once ;  for  the  muscles 
jerk  and  pull  as  seem  to  them  best,  taking  no  heed  of  the  time  or 
the  manner  in  which  the  will  wishes  any  movement  executed.  In 
some  cases  the  muscles  of  deglutition  and  of  respiration  become 
implicated,  and  difficulty  in  swallowing  and  in  breathing  occurs. 
A  dilated  pupil,  too,  acting  sluggishly  in  response  to  light,  may 
be  met  with  among  the  phenomena  of  the  malady. 

Chorea  is  essentially  a  functional  disorder  of  the  nervous 
centres.  In  a  large  number  of  persons  the  malady  is  called  into 
existence  by  an  irritation  of  peripheral  portions  of  the  nervous 
system.  Thus,  a  blow,  a  wound  of  a  nerve,  disorders  of  the 
uterus,  painful  menstruation,  pregnancy,  eye-strain,  or  gastric  or 
intestinal  affections  may  act  as  the  exciting  cause  of  the  perverted 
muscular  movements.  In  cases  due  to  organic  causes,  plugging 
of  the  vessels  leading  to  the  corpus  striatum  is  found  to  be  a 
common  lesion,  a  one-sided  embolism  giving  rise  to  one-sided 
chorea.*  And  the  association  with  vegetations  on  the  valves  is 
in  fatal  cases  certainly  very  frequent. f  It  has,  indeed,  been  sug- 
gested that  the  wild,  maniacal  delirium,  with  subsequent  rapid 
emaciation,  which  we  meet  with  in  some  instances  of  chorea,  has 
its  origin  in  embolism. |  But  all  cases  of  chorea  cannot  be  ex- 
plained by  minute  cerebral  embolism,  as  has  been  attempted. 

Chorea  may  be  produced  by  strong  mental  emotion,  especially 
by  fright.  It  may  follow  scarlet  fever,  but  it  is  more  often  the 
sequence  of  rheumatic  fever  or  arises  from  the  same  diathesis  that 
attends  or  occasions  rheumatism.  Yet  this  is  not,  as  some  have 
alleged,  its  only  cause ;  for  in  a  number  of  persons  affected  with 
chorea  we  fail  to  detect  any  proof  of  a  rheumatic  diathesis.  And 
as  regards  the  cardiac  complication,  the  presence  of  which  is  chiefly 
deduced  from  the  existence  of  a  murmur,  the  inference  drawn  from 
this  sign  is  hardly  a  fair  one ;  for  it  is  often  due  to  ansemia,  or 

*  Hughlings  Jackson,  London  Hospital  Keports,  vol.  ii.,  and  Edinburgh 
Medical  Journal,  Oct.  1868. 

f  Ogle,  British  and  Foreign  Medico-Chirurgical  Keview,  1868. 
X  Tuckwell,  iiicL,  Oct.  1867. 


198  MEDICAL    DIACxXOSIS. 

dependent  upon  spasmodic  action  of  the  papillary  muscles, — the 
same  spasmodic  action  that  is  seen  in  the  striated  muscles  of  the 
face  and  of  the  extremities. 

The  disease  is  rarely  fatal:  but  it  is  not  of  sliort  duration; 
for,  although  it  may  be  acute,  it  commonly  lasts  for  months,  and 
relajises  are  frequent.  There  are  in  chronic  cases  no  cerebral 
symptoms  attending  it,  yet  the  mental  faculties  are  not  in  a  ])cr- 
fectly  healthy  state.  The  intellect  of  a  choreic  child  develoj)S 
slowly,  and  is  evidently  enfeebled  Avhile  the  disorder  lasts.  In 
some  cases  paralysis  supervenes ;  but  it  is  not  permanent,  nor, 
indeed,  of  long  duration.  But  those  who  have  been  choreic  re- 
main subject  to  nervous  disorders  ;  and  I  have  known  several  in- 
stances in  which  the  complaint  has  been,  in  after-years,  followed 
by  epilepsy. 

The  diagnosis  of  chorea  is  generally  easy.  The  peculiar  habit 
some  children  or  even  older  persons  get  into  of  winking,  or  jerk- 
ing the  head,  or  other  irregular,  strange  movements,  the  "  habit- 
chorea"  or  "  habit-spasm,"  as  it  has  been  called,  is  distinguished 
by  its  gradual  development,  its  bilateral  character,  and  its  limita- 
tion to  a  particular  part.  Chorea  with  loss  of  power  on  one  side, 
"  paralytic  chorea,"  when  confined  to  the  arm  is  in  children  rec- 
ognized by  the  occasional  choreic  movements  observed,  and  the 
loss  of  power  Avhich  happens  gradually.  Chorea  from  eye-strain 
is,  as  a  ready  test,  discriminated  by  the  use  of  atropine.  Dr. 
Hansell  used  this  in  many  cases  at  my  clinic  with  quick  results. 
Atropine  paralyzes  the  ciliary  muscle ;  no  effort  of  accommoda- 
tion can  now  be  made ;  therefore  chorea,  as  well  as  headache  or 
other  functional  disturbances  from  disordered  accommodation, 
must  cease  after  an  interval  of  time  long  enough  to  break  up 
the  habit ;  chorea  from  constitutional  causes  will,  of  course,  be 
unaffected  by  atropine  or  other  paralysis  of  the  ciliary  muscle. 

Chorea  differs  from  the  spasms  of  acute  cerebral  disease  by  the 
absence  of  fever,  of  delirium,  and  of  coma,  though  we  must  bear 
in  mind  that  we  sometimes  have  mania  in  the  chorea  of  preg- 
nancy ;  from  epilepsy,  by  its  being  continuous,  by  the  non-exist- 
ence of  unconsciousness,  and  by  the  rarity  with  which  the  muscles 
jerk  at  a  time  when  epileptic  convulsions  are  frequent, — at  night ; 
from  tetanus  it  is  chiefly  distinguished  by  not  exhiliiting  tonic 
spasm.     Paralysis  agitans  is,  like  chorea,  attended  with  disturbed 


DISEASES    OF    THE    BRAIN    AND    SPINAL    C(niD.  109 

muscular  movements.  But  we  find  weakness  of  tlie  muscles  and 
persistent  tremor  rather  than  si)asmodic  contraction  and  want  of 
control  over  muscular  motion.  Then  the  history  of  the  case,  and 
the  signs  of  general  decay  associated  with  the  trembling,  clearly 
distinguish  paralysis  agitans.  In  cerebrospinal  sclerosis,  the  nys- 
tagmus, the  scanning  speech,  the  occurrence  of  the  jerks  only 
when  the  muscles  are  put  into  motion,  unlike  the  abrupt  and 
erratic  movements  of  chorea^  and  a  persistence  in  the  direction 
given  to  the  motion  notwithstanding  the  oscillations,  are  most 
significant.  Both  affections,  too,  are  encountered  in  persons  older 
than  are  generally  subject  to  chorea ;  especially  is  paralysis  agi- 
tans. Multiple  sclerosis  happens,  however,  also  in  children,  and 
we  meet  with  cases  of  paralysis  agitans  nearly  affiliated  to  chorea  ; 
like  it,  too,  originating  in  fright.  But  they  differ  in  the  motions 
repeating  themselves  rhythmically  and  symmetrically  on  the  two 
sides  of  the  body,*  and  in  presenting  nothing  of  the  irregular  and 
rapidly  changing  character  of  the  true  choreic  movements. 

Convulsive  tremor,  a  name  given  by  Hammond  to  a  paroxysmal 
affection  in  which  severe  muscular  tremor  arises  several  times  in  a 
day,  differs  from  chorea  in  not  being  continuous,  as  it  occurs  in 
attacks  lasting  from  fifteen  to  twenty  minutes,  passing  off  grad- 
ually, and  leaving  the  patient  in  a  profuse  perspiration.  The 
seizures,  moreover,  in  their  sudden  onset  resemble  more  an  attack 
of  epilepsy,  and  there  is  slight  headache,  with  vertigo,  and  an  in- 
tense feeling  of  anxiety,  without,  however,  unconsciousness.  The 
unrestrainable  tremor  affects  the  face,  the  arms,  and  the  trunk, 
but  not  the  lower  extremities,  and  is  associated  with  increased 
sensibility  of  the  skin  of  the  disturbed  parts. 

In  athetosis,  the  disease  described  by  Hammond,  there  is  con- 
tinual motion  of  the  fingers  and  toes,  with  inability  to  retain  them 
in  any  position  in  which  they  may  have  been  placed.  Great  ten- 
dency to  distortion  exists  in  the  mobile  spasm,  and  we  find,  on 
the  whole,  much  resemblance  to  localized  chorea.  But  the  malady 
generally  comes  on  with  epileptic  paroxysms ;  and  headache, 
vertigo,  slowness  of  speech  and  of  thought,  tremnlousness  of  the 
tongue,  numbness  of  the  affected  side,  and  pains  in  the  limbs 
which  are  the  seat  of  the  spasms,  give  us  a  very  different  clinical 

*  As  in  the  case  recorded  by  Sanders,  Edin.  Med.  Journ.,  May,  1865. 


200  MEDICAL   DIAGNOSIS. 

picture  from  chorea.  Athetosis  is  supposed  to  be  due  to  disease 
of  a  cortical  ceutrc.  It  has  been  observed  to  be  bilateral  in  idiotic 
children.  Similar  to  it  is  the  mobile  spasm  that  may  be  noticed 
in  palsied  limbs,  the  post-hemiplegic  chorea. 

Facial  8jX(i<m  differs  from  the  spasmodic  contractions  of  chorea 
in  being  always  of  equal  intensity,  and  in  the  grimaces  being 
strictly  confined  to  the  same  group  of  muscles,  and  generally 
existing  only  on  one  side  of  the  face. 

The  vrifcr^s  cramp,  an  affection  in  ^\■hicll  every  attempt  at 
writing  at  once  produces  spasmodic  action  of  the  muscles  of  those 
fingers  which  are  brought  into  play,  is  separated  from  chorea  by 
its  occurrence  in  individuals  who  have  strained  their  muscles  in 
using  a  pen  continuously  and  rapidly  ;  by  the  almost  instant  ces- 
sation of  the  spasm  when  the  afflicted  person  ceases  to  write ; 
and  by  the  ease  with  which  the  fingers  perform  other  motions 
and  are  capable  of  being  used  for  every  purpose  except  the  one 
which  has  brought  on  the  disorder.  A  very  analogous  complaint 
is  sometimes  encountered  in  seamstresses ;  also  in  telegraph-oper- 
ators, particularly  those  who  use  the  Morse  instrument.  These 
cramps,  and  all  those  of  a  similar  kind  caused  by  the  occupation, 
such  as  in  piano-players,  in  violinists,  and  in  type-writers,  have 
the  same  diagnostic  sign  that  has  just  been  mentioned  as  charac- 
teristic of  writer's  cramp, — namely,  that  the  spasm  befalls  only 
those  muscles  the  overstrain  of  which  has  led  to  the  affection,  and 
that  it  ceases  when  the  fatigued  muscles  are  kept  at  rest  or  are 
brought  into  action  for  a  different  purpose.  A  form  of  cramp 
like  that  of  writer's  cramp,  it  has  been  shown,  happens  in  those 
engaged  in  preparing  photographic  plates  ;*  and  I  have  seen  it  in 
turners,  engaged  in  what  is  called  "  oval  turning." 

There  is  a  disorder,  closely  allied  to  chorea,  which  consists  in 
repeated  violent  bobbings  of  the  head,  lasting  many  minutes  at 
a  time.  These  salaam  convulsions,  as  Sir  Charles  Clarke  calls 
them,  are  a  very  obstinate  complaint.  They  are  most  commonly 
met  with  in  children,  but  have  been  known  to  occur  in  adults  f  aiid 
to  lead  frequently  to  impairment  of  the  intellect.| 

Hysteria. — This  description  of  hysteria  will  deal  chiefly  with 

*  Napias,  Gazette  Medicale  de  Paris,  No.  40,  1883. 

t  Levick,  Amer.  Journ.  Med.  Sci.,  Jan.  1862. 

X  Henry  Barnes,  Liverpool  and  Manchester  Hospital  Keports,  1873. 


DISEASES    OP    THE    BRAIN    AND    SPINAL    CORD.  201 

the  symptoms  of  an  hysterical  paroxysm.  Most  of  the  Icjcal  hys- 
terical affections  have  been,  or  will  be,  considered  in  connection 
with  the  diseases  they  ape ;  and  to  discuss  any  questions  relating 
to  the  nature  of  this  perplexing  makidy,  or  to  attempt  to  scruti- 
nize or  to  interpret  all  the  false  and  contradictory  signals  it  hangs 
out,  is,  in  a  work  of  this  kind,  manifestly  impossible. 

An  hysterical  fit  may  set  in  suddenly,  under  the  influence  of 
some  violent  mental  emotion ;  but  more  generally  it.  is  preceded 
by  altered  spirits,  by  a  sensation  of  pressure,  and  of  constriction 
at  the  pit  of  the  stomach,  which  feeling  ascends  to  the  throat,  and 
is  likened  by  the  patient  to  the  rising  of  a  ball.  She  becomes 
much  agitated,  sobs,  laughs,  cries,  her  muscles  contract  violently, 
or  she  lies  motionless,  and  apparently  without  the  power  of  mo- 
tion, until  lier  seeming  insensibility  is  disturbed  by  something  she 
disapproves  of,  or  fears.  The  heart  palpitates ;  the  breathing  is 
irregular  and  heaving, — on  account,  perhaps,  of  an  affection  of 
the  larynx,  but  not  of  its  temporary  closure,  which,  as  Marshall 
Hall  tells  us,  so  commonly  ensues  in  epilepsy. 

These  hysterical  outbursts  differ  from  the  spasms  of  chorea  by 
their  remissions,  the  patient  remaining  at  times  for  months  free 
from  the  convulsive  movements.  Moreover,  there  is  not  even  par- 
tial or  apparent  unconsciousness  in  chorea.  It  is  true  that  this 
malady  and  hysteria  are  sometimes  combined,  or  rather  that  chorea 
happens  in  hysterical  subjects,  and  is  then  brought  about  by  imi- 
tation, and  is  apt  to  come  on  suddenly  ;  yet  it  is  remarkable  how 
rarely  fits  of  hysteria  take  place  in  those  affected  with  chorea. 

It  is  sometimes  very  difficult  to  distinguish  between  paroxysms 
of  hysteria  and  of  epilepsy ;  and  it  becomes  the  more  difficult  if 
the  epileptic  seizures  occur  in  hysterical  patients.  Yet  there  are 
ordinarily  many  well-marked  points  of  distinction  between  the 
two  maladies,  as  will  be  seen  from  this  table  : 

Epilepsy.  Hysteria. 

Sudden  and  complete  loss  of  conscious-  Gradual  and  only  partial  or  apparent 

ness.  unconsciousness. 

Livid   face;    escape    of    frothy   saliva  Face  flushed,  or  complexion  unaltered  ; 

from  the  mouth  ;  eyelids  half  open  ;  no   froth   on    lips  ;     eyelids   closed  ; 

eyeballs    rolling ;    grinding    of    the  eyehalls  fixed ;  neither  grinding  of 

teeth  ;    biting  of  the  tongue  ;    more  the  teeth  nor  biting  of  the  tongue  ; 

or  less  insensibility  of  the  pupils  to  pupils  react  readily. 

light. 


202  .MEDICAL    DIAGNOSIS. 

Epilepsy.  Hysteria. 

Distortion  of  countenance.  No  distortion  of  countenance. 

Patient  evinces  no  feeling.  Patient  sighs,  or  laughs,  or  sobs. 

Aura  epileptica.  Globus  liystericus. 

Convulsions    often    more    marked    on  lS\i  such  dill'crence  ;  eiuivulsions  clonic. 
one  side   than   on   the   other ;    and 
more  tonic  than  clonic. 

Paroxysm    generally    of   short    dura-  Paroxysm   generally  of  longer  dura- 
tion, tion. 

Paroxysm  followed  by  a  heavy,  half-  Paroxj'sm   not  followed   specially  l.iy 

comatose    sleep,   by   headache,   and  sleep ;    patient   often,   after    attack 

by  dulness  of  intellect.  terminates,  wakel'ul    and    depressed 

in  spirits. 

Frequently  occurs  at  night.  Rarely  occurs  at  night. 

No  particular  connection  with  uterine  Often  connected  with  disorders  of  the 

disturbance,    although    a    paroxysm  uterus,  or  of  menstruation. 
often   takes   place  at  the  menstrual 
period. 

There  are,  however,  spasms  that  occur  in  hysterical  patients 
which,  though  a  functional  nervous  ajffection,  appear  like  a  blend- 
ing of  hysteria  and  epilepsy.  Charcot*  particularly  has  called 
attention  to  this  hystero-epilepsy,  and  describes  its  distinctive  traits 
as  consisting  in  premonitory  symptoms  of  rather  long  duration, 
and  exhibiting  an  aura  which,  starting  in  most  cases  from  the 
ovarian  region,  advances  progressively  to  the  head.  The  cry  is 
prolonged  and  modulated,  not  short  like  the  epileptic  cry.  The 
convulsions  are  identical;  but,  instead  of  entering  subsequently 
upon  a  stage  of  snoring,  the  hystero-epileptic  sobs,  laughs,  ges- 
ticulates violently,  or  is  delirious  and  subject  to  hallucinations. 
In  the  ovarian  form  of  hystero-epilepsy,  pressure  u^xni  the  ovary 
will  invariably  modify  the  symptoms,  if  not  completely  arrest  the 
attack  ;  whereas  in  epilepsy  no  such  effect  is  produced.  In  the 
cases  of  hystero-epilepsy  Avith  repeated  attacks,  the  temperature 
scarcclv  rises  above  the  normal,  as  it  rapidly  docs  under  similar 
circumstances  in  epilepsy.  There  is  no  epileptic  vertigo  ;  there  are 
no  abortive  fits.     Charcot  has  also  observed  the  malady  in  men. 

Hvsteria  is  not  an  affection  merely  of  paroxysms.  In  the  in- 
tervals between  them  Ave  find  peculiar  and  significant  manifesta- 
tions of  the  strange  complaint,  which  should  be  understood,  lest 

*  Lectures  on  Diseases  of  the  Nervous  System,  collected  by  Bourneville. 
See  also  Richer,  Etudes  cliniques  sur  Hystero-Epilepsie,  Paris,  1881. 


DISEASES   OF   THE    BRAIN    AND    SPINAL    CORD.  203 

they  be  taken  as  the  signs  of  other  troubles.  We  ol)serve  an  ex- 
treme susceptibility  of  the  nervous  system,  various  hyper£esthesia3, 
such  as  tenderness  in  the  epigastrium  or  in  the  course  of  the  spinal 
column  or  over  the  ovary;  that  peculiar  pain  in  the  left  side  wliich 
distresses  so  many  hysterical  and  ansemic  women ;  and  sometimes 
local  anaesthesia.  Besides  these,  we  encounter  manifold  local  hys- 
terical ailments,  such  as  hysterical  paralysis,  hysterical  aphonia, 
hysterical  peritonitis,  hysterical  affections  of  joints,  hysterical  pain 
in  the  forehead,  hysterical  suppression  as  well  as  hysterical  reten- 
tion of  urine.  Hysterical  laughter  has  been  found  to  occur  on  a 
large  scale  as  a  form  of  epidemic  convulsion.*  Hysteria  is  met 
with  in  the  male,  especially  after  railway  accidents.t  Hysterical 
paralysis  may  also  happen  in  either  sex,  in  the  shape  of  hemiplegia, 
of  monoplegia,  or  of  paraplegia.  As  regards  hysterical  hemiplegia, 
it  is  remarkable  that  it  does  not  affect  the  face. 

The  distinction  between  these  hysterical  pseudo-maladies  and 
the  diseases  they  simulate  is  far  from  being  an  easy  task.  We 
have  to  take  into  account  the  patient's  age  and  sex ;  the  existence 
of  any  irregularity  in  the  uterine  functions ;  whether  or  not  she 
has  suffered  from  paroxysms  of  hysteria ;  how  the  pain  is  influ- 
enced by  pressure ;  and  the  signs  of  functional  disorder  of  the 
apparently  affected  part.  We  may  thus  avoid  mistaking  a  phan- 
tom for  a  true  disease.  Yet  there  is  another  and  opposite  source 
of  error  quite  as  strenuously  to  be  guarded  against.  The  com- 
plaint may  be  really  an  organic  one,  occurring  in  an  hysterical 
patient,  and  concealed,  or  exaggerated  and  complicated,  by  the 
symptoms  of  hysteria.  In  all  such  doubtful  cases  we  must  accord 
great  weight  to  the  extent  of  functional  and  constitutional  dis- 
turbance accompanying  the  local  morbid  state.  Then,  too,  hvs- 
terical  symptoms  may  be  prominent  in  certain  brain  affections.  I 
have  repeatedly  noticed  them  in  cases  of  cerebral  embolism  ;  and 
Brown-Sequard  and  Seguin  j  have  shown  their  frequent  occurrence 
in  lesions  of  the  right  hemisphere. 

Hysteria  is  sometimes  feigned, — feigned  to  elicit  sympathy,  or 
to  procure  compliance  with  wishes  or  caprices.  Xor  is  the  simu- 
lation of  the  disorder  an  outgrowth  from  our  civilization.     The 

*  D.  W.  Tandell,  Brain,  Oct.  1881. 

f  Putnam,  Amer.  Journ.  of  Neurology,  1884. 

j  Archives  of  Electrology  and  ISTeurology,  May,  1875. 


204  MEDICAL   DIAGNOSIS. 

ep^igrams  of  Martial  prove  how  common  the  feigning  of  hysteria 
Mas  among  the  Koman  women. 

Tetanus. — -V  disease  marked  by  persistent  rigid  eoutractiou 
of  the  voluntary  muscles,  particularly  of  those  of  the  jaw. 

This  distressing  malady,  as  we  see  it,  is  generally  traumatic, 
following  a  wound  or  an  injury;  for  idiopathic  tetanus  is  very 
seldom  met  with  in  temperate  climates.  But  in  liot  countries,  or 
in  those  in  which  sudden  alternations  of  temperature  are  common, 
it  is  not  a  rare  disease,  and  is  indeed  frtxpient  among  new-born 
childi'cn.  The  cases  of  idiopathic  tetanus  we  encounter  are  almost 
always  the  result  of  exposure  to  cold.  The  malady  is  also  seen 
in  the  puerperal  state. 

The  muscles  ordinarily  first  affected  are  those  of  the  jaw  and 
neck ;  there  is  a  stiffness  about  them  which  the  patient  is  apt  to 
attribute  to  having  caught  cold.  Sometimes,  however,  the  dis- 
order exhibits  itself  primarily  in  the  external  respiratory  muscles. 
When  the  malady  is  fully  developed,  most  of  the  muscles  are  stiff' 
and  hard,  the  jaw  cannot  be  opened, — whence  the  common  name 
of  lock-jaw, — and  there  is  much  difficulty  in  speaking  and  in 
swallowing.  With  these  symptoms  we  usually  find  rigidity  of 
the  muscles  of  the  abdomen  and  of  the  limbs,  and  a  distressing 
pain  at  the  pit  of  the  stomach,  dependent  upon  spasms  of  the 
diaphragm.  Besides  the  permanent  contraction  of  the  voluntary 
fibres,  exacerbations  of  spasm  take  place,  during  wliich  the  muscles 
become  very  hard.  These  paroxysms  are  accompanied  by  intense 
pain,  and  recur  with  increased  severity  and  frequency  as  the  dis- 
ease advances  to  a  fatal  termination.  When  at  their  height,  the 
body  becomes  curved,  the  patient  merely  resting  upon  his  head 
and  heels.  This  is  opisthotonus ;  while  the  setting  of  the  jaw, 
especially  when  its  muscles  alone  are  affected,  is  called  trismus. 

Notwithstanding  the  striking  muscular  disorder  and  the  ex- 
hausting pain,  there  is  little  constitutional  disturbance ;  the  pulse 
may  be  quickened,  but  it  preserves  its  volume  until  the  last  stage 
is  reached  ;  and  there  is  often  no  fever,  nor  is  the  intellect  affected. 
But  the  temperature  shows  extraordinary  variations.  The  ther- 
mometer may  mark  an  increase  of  several  degrees  in  the  evening,* 
and  toward  the  end  show  a  heat  of  110°. 

*  Ogle,  Clinical  Society's  Transactions,  1872. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  205 

Tetanus  runs  an  acute  or  a  chronic  course.  Some  cases  last 
three  weeks,  and  when  of  such  long  duration  are  apt  to  recover. 
But  generally  the  malady  terminates  fatally  before  the  eighth  day. 

Few  complaints  are  likely  to  be  confounded  with  tetanus ;  yet 
these  few  resemble  it  closely  in  many  respects.  For  instance,  one 
of  the  freaks  of  hysteria  is  to  take  the  appearance  of  tetanus ;  and 
tonic  spasms  dependent  upon  an  affection  of  the  spinal  cord  or 
medulla  oblongata,  strychnine  poisoning,  or  hydrophobia,  may 
accurately  simulate  its  symptoms. 

Hysterical  tetanus  is  distinguished  from  the  real  disease  by  being 
preceded  by,  or  attended  with,  fits  of  hysteria ;  by  the  age  and  sex 
of  the  patient ;  by  the  absence  of  pain  ;  by  the  occasional  occur- 
rence of  clonic  instead  of  tonic  spasms  ;  and  by  the  intermission 
every  now  and  then  of  all  muscular  rigidity.  Moreover,  the  in- 
fluence of  the  mind  upon  the  seeming  tetanus  is  very  striking.  If 
within  hearing  of  the  patient  the  employment  of  cold  to  the  spine, 
or  of  the  cautery,  be  threatened,  or,  better  still,  if  the  latter  instru- 
ment be  actually  made  ready  for  use  before  her,  an  extraordinary 
subsidence  of  all  stiffening  and  starting  of  the  limbs  takes  place. 
Hysterical  trismus  is  more  common  than  more  extended  hysterical 
tetanoid  spasm,  but,  besides  the  symptoms  of  hysteria  just  men- 
tioned, the  absence  of  rigidity  in  the  neck  is  very  significant. 

Tetanic  spasms  symptomatic  of  an  affection  of  the  spinal  cord 
are  separated  from  tetanus  by  the  different  history  ;  by  no  violent 
exacerbations  being  brought  on,  as  they  are  in  tetanus,  by  slight 
movements,  or  by  an  attempt  at  speaking,  or  by  any  reflex  irrita- 
tion ;  by  the  absence  of  marked  remissions ;  by  the  rigidity  being 
almost  always  limited  to  the  extremities — except  in  the  case  of 
meningeal  apoplexy  in  the  cervical  region,  in  which  the  tonic  con- 
traction in  the  upper  extremity  is  associated  with  stiffness  of  the 
neck ;  and  by  the  setting  in  of  palsy  before  the  malady  terminates. 

In  the  tetanic  spasms  which  may  occur  in  scarlet  fever,  in 
typhus,  in  smallpox,  or  in  pyaemia,  and  which  are  the  result  of 
an  irritation  of  the  cord  produced  by  the  poisoned  blood,  the 
rigidity  runs  so  uncertain  a  course,  appears  so  quii'kly,  disappears 
so  suddenly,  perhaps  not  to  reappear,  or  only  to  reappear  after  a 
considerable  interval,  that  there  is  little  likelihood  of  confound- 
ing the  muscular  disorder  with  tetanus.  In  cerebrospinal  fever 
the  resemblance  is  much  closer  :  yet  the  whole  history  of  the  dis- 


206  MEDICAL    DIAGNOSIS. 

order,  the  state  of  the  niliul,  and  the  progress  of  the  case,  are  such 
as  to  prevent  error.  A\"ith  muscular  rheumatism  tetanus  can  only 
be  confounded  at  its  onset.  But  the  muscles  of  the  jaw  are  not 
rigid  in  rheumatism. 

Another  form  of  symptomatic  rigidity  requires  to  be  distin- 
guished from  tetanus, — a  local  rigidity,  owing  to  the  irritation 
of  the  nerve  supplying  the  stiffened  muscles ;  as,  for  instance,  a 
spasm  from  irritation  of  the  peripheral  or  the  central  tract  of  the 
motor  portion  of  the  fifth,  the  so-called  "  masticatory  spasm"  of 
the  face.  This  ailment  may  be  of  reflex  origin,  the  exciting  cause 
being  a  decayed  tooth,  a  wound,  or  exposure  to  cold;  or  it  may 
exist  in  connection  with  apoplexy,  or  with  an  inflammation  of  the 
brain.  Its  main  marks  of  distinction  from  the  trismus  of  tetanus 
are,  that  it  is  purely  local,  is  often  of  long  continuancej  is  not 
painful,  has  no  paroxysms  of  aggravation,  is  not  combined  with 
impaired  deglutition,  and  is  not  dangerous.* 

Intermittent  tetanus,  or  tetany,  is  characterized  by  tonic  contrac- 
tions, more  especially  of  the  legs  and  arms,  occurring  at  intervals  ; 
the  toes  are  apt  to  be  flexed  toward  the  soles ;  the  hands  become 
fixed ;  the  spasm  begins  in  the  extremities.  The  jaws  and  the 
respiratory  muscles  are,  unlike  what  we  find  in  true  tetanus,  not 
affectedjt  or  the  jaws  become  so  only  toward  the  end. 

The  spasms  are  painful ;  they  may  occur  ses^eral  times  in  a  day, 
or  there  may  be  weeks  between  them.  They  can  also  be  pro- 
duced, as  Trousseau  discovered,  by  pressure  on  the  chief  arteries 
and  nerves  of  the  affected  limb.  They  are  usually  preceded  by 
tingling  or  burning ;  in  the  intervals  between  them  the  muscles 
are  readily  excited  to  contraction  and  there  is  increased  electrical 
excitability ;  the  temperature  remains  normal  throughout.  The 
contractions  are  bilateral,  which  distinguishes  them  from  hysteri- 
cal contractures.  The  malady  happens  chiefly  in  children,  or  in 
women  after  confinement.  It  has  been  described  as  occurring  in 
an  epidemic  form,  and  the  symptoms  mentioned  are  like  those  of 
ergot  poisoning.  J 

*  Bright,  in  the  second  volume  of  his  Medical  Keports,  gives  the  particulars 
of  a  case  which  illustrates  many  of  the  difficulties  of  diagnosis  to  which  the 
affection  may  give  rise. 

f'Wilks,  Guy's  Hospital  Eeports.  3d  Series,  vol.  xvii. 

:j:  Stated  in  the  German  translation  of  this  hook. 


DISEASES    OF    THE    BRAIN   AND    SPINAL    CORD.  207 

The  symptoms  of  strychnine  poinoning  are  almost  identical  with 
those  of  tetanus  ;  yet  there  are  some  characteristic  differences.  The 
spasms  from  strychnine  do  not  supervene  upon  exposure  to  cold, 
or  upon  a  wound,  but  follow  within  about  two  hours  or  less  the 
taking  of  some  solid  or  liquid.  They  come  on  suddenly,  with 
violence,  and  with  epigastric  pain  and  early  reflex  excitability. 
The  tetanoid  convulsions  affect  simultaneously  nearly  all  the  vol- 
untary muscles  of  the  body,  but  with  greatest  intensity  those  of  the 
trunk  and  spine,  producing  very  early — within  a  few  minutes,  com- 
monly— a  marked  opisthotonus,  which  in  tetanus  does  not  appear, 
if  it  appear  at  all,  for  many  hours  or  for  days  after  the  seizure. 
On  the  other  hand,  the  stifiiiess  of  the  jaws,  which  is  among  the 
very  earliest  signs  of  tetanus,  is  not  at  first  perceived  in  strychnine 
poisoning,  and,  if  it  occur,  occurs  only  imperfectly.  Further,  we 
do  not  see  the  frightful  tetanic  face,  with  its  knit  brow  and  horrid 
grin ;  we  do  not  observe  intermissions  in  the  convulsions,  or  diffi- 
culty in  swallowing ;  and  in  from  ten  minutes  to  two  hours  after 
the  commencement  of  the  attack  the  patient  dies  or  recovers. 

Finally,  let  us  contrast  tetanus  with  hydrojyhobia.  Both  show- 
ing the  reflex  functions  of  the  spinal  cord  to  be  in  an  exalted  con- 
dition ;  both  being  spasmodic  affections  lasting  ordinarily  but  a 
few  days ;  both  taking  place,  the  popular  opinion  to  the  contrary 
notwithstanding,  at  all  periods  of  the  year ;  both  presenting  violent 
paroxysms  of  convulsions,  which  are  often  excited  by  the  slightest 
touch  or  jar  to  the  body ;  both  frequently  occasioning  torturing 
pain  near  the  pit  of  the  stomach ;  both  ensuing  commonly  upon 
an  injury ;  both  usually  augmenting  in  intensity  from  hour  to 
hour,  and  scarcely  within  the  reach  of  therapeutic  measures,— 
these  ghastly  maladies  are  yet  dissimilar.  In  the  one,  deglutition 
may  be  difficult ;  in  the  other,  it  is  next  to  impossible,  all  attempts 
at  swallowing,  especially  of  fluids,  exciting  the  most  distressing 
spasmodic  dysphagia.  In  the  one,  early  rigidity  of  the  muscles 
of  the  jaw  happens ;  in  the  other,  there  is  no  such  rigidity.  In 
the  one,  the  breathing  may  or  may  not  be  interfered  with ;  in  the 
other,  the  spasms  of  respiration  are  almost  as  marked  a  feature  as 
the  spasms  of  deglutition.  Then  the  irritability  of  temper  in  hy- 
drophobia ;  the  fierce  manner  of  the  patient ;  his  rabid,  perhaps 
maniacal  paroxysms;  the  constant  thirst;  the  accumulation  of 
stringy  mucus  about  the  angles  of  the  mouth ;    the  vomiting ; 


208  MEDICAL   DIAGNOSIS. 

the  acute  sensibility  of  the  surface  ;  the  trembling  of  the  muscles ; 
the  clonic?  instead  of  tonic  S])asms  ;  the  strano-ling-  sensation  in  the 
throat, — are  phenomena  too  strikingly  peculiar  to  render  an  error 
in  diagnosis  likely.  Some  of  the  points  licre  referred  to  serve 
also  to  distinguisli  hydrophobia  from  acute  mania,  and  from  hys- 
teria. For  as  in  tetanus,  so  here  we  find  this  erratic  complaint 
simulating-  tlic  terrible  disease. 

Functional  Spasms. — There  are  spasms  that  take  i)lace  in 
various  parts  of  the  body,  sometimes  clonic  spasms,  sometimes 
tonic  spasms,  which  occur  without  apparent  cause,  and  are  more 
or  less  continuous  or  persistent.  In  time  they  may  lead  to  con- 
tractures and  deformity,  or  they  may  pass  a^^'ay.  They  may  be 
of  hysterical  origin ;  but  these  are  not  now  under  discussion, 
rather  the  spasms  that  take  place  in  one  or  both  legs,  sometimes 
in  the  arms,  occasionally  in  the  muscles  of  the  face,  which  occur  in 
those  who  are  not  hysterical  subjects,  and  are  not  traceable  to  any 
lesions.  Pressing  on  particular  points  may  at  once  excite  them  ;  on 
the  other  hand,  there  are  "pressure-points"  wliich  when  acted  on 
will  cause  the  convulsive  movements  to  be  arrested.  The  trophic 
disturbance  that  attends  them  is  usually  very  slight.  •  Tonic  con- 
tractions are  very  apt  to  alternate  with  clonic  spasms,  or  there 
may  be  only  complete  tonic  spasm  during  attempts  at  moving- 
certain  muscles.  At  times  spasms  of  the  internal  muscles,  as  those 
of  deglutition  or  respiration,  may  coexist ;  or  the  spasms  may  be 
limited  to  these  muscles.     The  disorder  is  sometimes  hereditary. 

There  is  a  curious  form  of  spasm,  a  tonic  contraction  of  the 
muscles,  which  impedes  locomotion.  It  shows  itself  when  the 
muscles  are  first  put  into  action  after  a  period  of  rest,  or  after 
an  unexpected  irritation,  as  striking  the  toes  against  a  stone  in 
walking,  and  is  increased  by  nervous  dread  about  it.  Happening, 
as  it  generally  does,  in  the  lower  extremities,  it  leads  there  to 
muscular  increase.  Tliis  Thomseii's  disease  has  been  known  to 
originate  in  sudden  fright.*     It  commonly  begins  at  an  early  age, 

*  Case  of  Schonfeld,  Berl.  Klin.  Wochenschrift,  July,  1883  ;  and  of  Engel, 
Phila.  Med.  Times,  Sept.  8,  1883.  See  also  cases  collected  by  Mobius, 
Schmidt's  .Tahrb.,  No.  6,  1883;  and  the  cases  by  Deligny,  Observation  d'lm 
Cas  de  Maladie  de  Thomsen,  Union  Med.,  Paris,  1885,  xxxix.  50-52;  Bern- 
hardt, Beitrag  zur  Pathologie  der  sogenannten  "  Thomsen 'schen  Krankheit," 
Centralbl.  f.  Nervenh.,  Leipz.,  1885,  viii.  122-126;  Hammond,  Thomsen's  Dis- 


DISEASES    OF   THE    BRAIN    AND    SPINAL    CORD.  209 

and  is  hereditary ;  it  is  very  persistent,  although  no  organic  cause 
for  it  has  been  detected.  In  the  morning,  on  first  rising,  the 
muscles  act  well,  but  when  the  contractions  are  in  any  way  ex- 
cited the  muscles  become  rigid  and  the  joints  fixed ;  yet  if"  exertion 
be  persevered  in,  the  spasm  becomes  less  and  less,  and  continued 
walking  is  possible  until  after  another  period  of  rest.  The  spasm 
very  rarely  affects  the  muscles  of  the  face. 

Diseases  characterized  by  Gradual  Impairment  of  the  Mental 
Faculties  with  Paralysis, 

Chronic  Softening. — There  are  two  main  forms  of  softening, 
— the  red  and  the  white.  The  former  is  inflammatory, — a  cir- 
cumscribed encephalitis, — and  runs  an  acute  course,  with  symp- 
toms, as  we  have  already  discussed,  often  closely  simulating  those 
of  apoplexy,  but  sometimes  with  signs  like  those  of  the  chronic 
malady,  and  differing  in  nothing  but  in  their  intensity  and  short 
duration.  The  second  kind  is  chiefly  dependent  upon  a  change  in 
the  nutrition  of  the  brain,  and  is  nearly  always  linked  to  a  dis- 
eased condition  of  the  cerebral  arteries  and  plugging  of  the  ves- 
sels ;  it  may,  however,  be  caused,  or  at  all  events  accompanied, 
by  an  inflammatory  exudation  infiltrated  among  the  nervous  pulp. 
These,  briefly,  are  its  early  symptoms :  gradual  impairment  of 
intelligence  ;  Aveakening  of  memory  ;  headache  ;  vertigo  ;  muscular 
debility ;  cutaneous  hypersesthesia  or  anaesthesia ;  formication  and 
numbness  ;  and  slight  and  partial  palsies,  particularly  of  the  mus- 
cles of  one  side  of  the  mouth,  or  of  one  eyelid.  Then  there  is  not 
unfrequently  defective  articulation,  with  great  irritability  of  tem- 
per, nausea  and  vomiting,  extreme  sensitiveness  to  sounds,  and 
painful  feelings  in  various  parts  of  the  body.  As  the  local  mis- 
chief advances,  the  paralysis  becomes  more  universal,  assuming 
generally  the  hemiplegic  form  ;  and  spasms,  either  tonic  or  clonic, 
or  epileptic  convulsions,  occur. 

ease,  GaiUard's  Med.  Journ.,  N.Y.,  1886,  xli.  614-617  ;  Fischer,  Ein  Fall  von 
Thomsen'scher  Krankheit,  Neurol.  Centralbl.,  Leipz.,  1886,  v.  73-78;  Delmas, 
Maladie  de  Thomsen  (Dysmyotonie  congenitale),  Journ.  de  Med.  de  Bordeaux, 
1886-87,  xvi.  97-100 ;  Buzzard,  Two  Cases  of  Thomsen's  Disease,  Lancet,  Lond., 
1887,  i.  972-974;  Mibeleisen,  Zur  Casuistik  der  Myotonia  congenita  oder 
Thomsen'schen  Krankheit,  Miinchen.  Med.  Wochenschr.,  1887,  xxxiv.  433; 
Dana,  Thomsen's  Disease,  Medical  Record,  April  21,  1888;  Blumenau,  Thom- 
sen's  Disease,  Neurologisches  CentralMatt,  1888,  p.  679. 

14 


210  MEDICAL    DIAGNOSIS. 

The  mental  decay  proceeds  steadily,  and  sometimes  shows  itself 
in  a  constant  rejietition  of  the  same  action  or  the  same  phrase.  In 
an  old  lady  Avhom  I  attended,  this  \vas  the  most  marked  symptom : 
she  was  constantly  complaining  that  her  teeth  needed  attention,  was 
perfectly  satisfied  when  assured  by  the  dentist  that  they  did  not, 
but  soon  reiterated  her  complaint.  Beyond  this,  and  a  most  painful 
sensitiveness  to  sound  and  to  light,  intense  headache,  nausea,  and  a 
progressive  deterioration  of  memory  and  of  the  faculty  of  thought, 
she  presented  no  signs  of  cerebral  softening.  She  died  without 
the  occurrence  of  paralysis. 

Softening  of  the  brain  may  be  caused  by  a  diseased  state  of 
the  cerebral  vessels,  or  by  their  obstruction  ;  by  long-continued 
grief;  by  persistent  mental  labor ;  by  constitutional  syphilis;  by 
frequently-repeated  epileptic  paroxysms ;  and  by  an  inflammatory 
disease  spreading  from  the  meninges  to  the  brain,  or  taking  place 
around  new  formations  and  old  lesions.  It  may  also  be  depend- 
ent upon  apoplexy.  At  all  events,  we  frequently  meet  with  it 
in  connection  \vith  hemorrhage,  and  associated  sometimes  in  such 
a  manner  as  to  make  it  a  very  perplexing  matter  to  ascertain  if 
the  softening  have  followed  the  extravasation  of  blood,  or  if  the 
extravasation  have  taken  place  into  an  already  diseased  brain. 
We  may  conclude  the  latter  to  have  occurred,  if  signs  of  deranged 
intellection  or  sensation  have  preceded  the  attack  and  are  more 
than  can  be  explained  by  disease  of  the  vessels ;  if  after  reaction 
from  the  shock,  the  patient,  instead  of  mending  in  mind,  exhibit 
unmistakable  evidences  of  progressing  mental  decay  ;  and  if  con- 
vulsive movements  or  rigidity  of  the  limbs  appear.  But  let 
us,  in  passing,  remark  that  a  small  clot  breaking  down  the  soft- 
ened cerebral  mass,  }'et  not  extending  beyond  the  limits  of  the 
diseased  texture,  occasions  no  special  signs, — occasions  only  the 
signs  of  a  sudden  giving  way  of  nerve-pulp  :  paralysis  Avithout 
unconsciousness. 

We  shall  next  study  how  various  other  cerebral  maladies,  such 
as  congestion,  anaemia,  abscess,  and  hardening,  may  be  distin- 
guished from  softening. 

Congestion  is  discriminated  by  its  being  very  rarely  a  persistent 
state.  An  acute  attack  produces  the  symptoms  of  apoplexy;  a 
more  lasting  congestion  is  recognized  by  tracing  the  cause  which 
has  led  to  the  fulness  of  the  vessels, — such  as  a  disease  of  the  heart 


DISEASES    OF   THE    BRAIN    AND    SPINAL    CORD.  211 

or  of  the  abdominal  viscera, — and  by  noting  that,  although  the 
patient  suffers  from  dull  headache,  from  jerking  of  the  muscles, 
from  pulsation  of  the  carotids,  from  vertigo,  these  signs  are  far 
from  being  constant,  and  come  and  go  for  a  long  time  without 
any  material  disturbance  of  the  functions  of  the  brain  being  per- 
ceptible, in  reference  either  to  thought  or  to  voluntary  motion. 
The  finding  of  optic  neuritis,  or  choked  disk,  would  settle  any 
doubt  against  congestion. 

Cerebral  ansemia,  occurring  suddenly,  produces  unconsciousness, 
or  dizziness  or  stupor ;  or,  if  very  general,  and  especially  if  asso- 
ciated with  venous  congestion,  it  may  cause  convulsions.  When 
more  gradually  induced,  it  manifests  itself  by  drowsiness,  distress- 
ing headache,  often  more  particularly  referred  to  the  vertex ;  by 
the  pale  face  and  uninjected  eye  with  large  pupil ;  by  derange- 
ment of  the  special  senses ;  by  the  vertigo  and  the  other  symptoms 
of  cerebral  disorder  being  relieved  in  the  recumbent  position ;  and 
by  the  feeble  pulse  and  cool  forehead.  Then  in  tracing  its  history 
we  are  apt  to  fincl  that  it  occurs  in  those  who  have  been  exhausted 
by  debilitating  diseases,  or  by  repeated  hemorrhages,  or  by  albu- 
minuria. The  chief  distinction  from  softening  lies  in  the  history 
of  the  case ;  the  aspect  of  the  patient,  too,  and  the  absence  of 
palsies,  or  their  passing  nature,  must  be  taken  into  account.  But 
we  must  not  forget  that  if  the  morbid  condition  be  long  continued, 
the  ill-nourished  brain  will  soften. 

Abscess  of  the  brain  differs  mainly  in  this  from  chronic  soften- 
ing :  the  disease  is  of  short  duration.  Some  cases  may  run  a  very 
rapid  course,  others  may  continue  for  months ;  yet  few,  as  Lebert  * 
has  informed  us,  last  longer  than  eight  weeks.  Further,  we  find 
in  abscess,  unlike  what  happens  in  softening,  convulsions  in  the 
earlier  period,  and  paralysis  late  in  the  malady ;  and  not  unfre- 
quently  we  discover,  in  analyzing  the  history,  that  chills  have 
occurred,  or  we  can  detect  the  clue  to  the  cerebral  abscess  in  a 
disease  of  the  internal  ear,  or  in  an  injury  to  the  head,  or  in  the 
presence  of  suppuration  in  some  distant  part  of  the  body.  In  the 
early  stages  abscess  is  often  latent ;  in  the  late  stages  the  signs  of 
oedema  of  the  brain,  delirium,  great  depression,  decided  headache. 


*  Archiv  fiir  Path.  Anat.,  Bd.  x.     See  also  Gull's  paper  in  Guy's  Hospital 
Keports,  3d  Series,  vol.  ili. 


212  MEDICAL    DIAGNOSIS. 

iinally  stupor,  are  likely  to  be  met  with  ;  and  at  any  stage  hemi- 
})logia  and  contractions  are  far  less  common  than  in  softening. 
Cases  of  red  softening  cannot  be  distinguished  from  cerebral 
abscess,  especially  from  those  cases  which  run  a  rapid  course.  In 
truth,  the  two  morbid  states  are  anatomically  related  and  often 
combined.  Abscess  of  the  brain  may  be  latent,  and  the  sudden 
rupture  of  the  abscess  may  give  rise  to  symptoms  undistinguish- 
able  from  those  of  hemorrhage,  undistinguishable  unless  we  can 
infer  an  abscess  from  a  disease  of  the  bones  of  the  skull,  or  from 
some  points  in  the  history  of  the  case. 

Atrophy  of  the  brain  is  especially  observed  in  old  age,  and  gives 
rise  to  the  general  decay  of  all  cerebral  functions  noticed  at  this 
period  of  life ;  in  children  it  is  found  not  unfrequently  in  connec- 
tion Avith  the  signs  of  chronic  hydrocephalus.  Atrophies  of  par- 
ticular portions  of  the  brain  are  met  Avith  following  injuries  or 
diseases  of  the  peripheral  parts  which  they  control,  and  can  gen- 
erally only  be  suspected,  not  surely  recognized. 

There  is  yet,  leaving  tumors  out  of  the  question,  another  affec- 
tion of  the  brain  Avhicli  may  be  confounded  with  softening  :  an 
exhaustion  of  brcdn-jjoicer,  encountered  among  professional  men 
or  those  engaged  in  laborious  literary  undertakings.  This  some- 
times comes  on  suddenly,  with  signs  like  those  of  a  collapse  ;  more 
generally  it  is  slower  in  development.  Its  manifestations  are  a 
slight  deterioration  of  memory,  and  an  inability  to  read  or  write, 
save  for  a  very  short  period,  although  the  power  of  thought  and 
of  judgment  is  in  no  way  perverted.  Nor  is  the  power  of  atten- 
tion more  than  enfeebled  :  the  sick  man  is  fully  capable  of  giving 
heed  to  any  subject,  but  he  soon  tires  of  it,  and  is  obliged  from 
very  fatigue  to  desist.  He  passes  sleepless  nights,  is  subject  to 
ringing  in  the  ears,  cannot  bear  much  exercise,  is  troubled  with 
irregular  action  of  the  heart,  with  a  frequent  desire  to  urinate,  and 
with  neuralgic  pains  in  the  face  or  a  feeling  of  soreness  in  the  head; 
but  he  does  not  lose  flesh,  and  his  digestion  is  uninjured. 

ISIany  remain  in  this  condition  for  months,  and  then  slowly 
regain  their  health.  What  the  precise  disturbance  of  the  brain 
consists  in,  is  uncertain  :  it  is  possible  that  the  nutrition  of  the 
organ  has  been  interfered  with  from  overuse  and  worry,  and  that 
the  further  continuance  of  mental  toil  and  anxiety  would  have  led 
to  softening.     The  phenomena  of  this  form  of  neurasthenia,  as  it 


DISEASES    OF    THE    BRAIN    AND    SPINAL   COIID.  213 

is  now  customary  to  call  the  disorder,  differ  from  those  of  soften- 
ing by  the  absence  of,  or  at  least  by  the  far  less  permanent  and 
marked,  headache,  by  the  comparatively  unimpaired  intelligence, 
and  by  the  non-concurrence  of  spasms,  or  of  paralysis  of  motion 
or  of  sensation. 

Let  us  now  consider  tJie  diagnosis  of  the  chief  varieties  of  soft- 
ening. In  how  far  is  it  possible  to  distinguish  the  inflammatory 
from  the  non-inflammatory  form  ?  The  more  acute  the  symptoms, 
the  greater  is  the  likelihood  of  their  being  due  to  an  inflammatory 
lesion ;  and  in  young  subjects  this  probability  becomes  almost  a 
certainty.  A  latency  of  the  affection,  its  slow  and  gradual  mani- 
festation, its  existence  in  persons  advanced  in  life,  and  in  whom 
we  have  reason  to  suspect  degeneration  of  the  coats  of  the  arteries, 
or,  on  the  other  hand,  a  history  pointing  to  closure  of  the  vessels 
by  a  plug,  or  to  an  embolus  washed  into  them  from  a  diseased 
heart,  are  facts  which  justify  the  conclusion  that  the  softening  is 
owing  to  a  depraved  nutrition  of  the  cerebral  substance,  and  not 
to  its  inflammation.  Softening  may  occur  in  the  brain  of  infants, 
but,  as  Parrot  *  show^s,  cannot  be  diagnosticated. 

Tumor. — Tumors  of  the  brain  give  rise  to  a  great  diversity 
of  signs,  according  to  their  locality,  their  size,  and  their  nature. 
Let  us  examine  the  group  of  symptoms  by  which  we  may  infer 
their  occurrence,  and  then  see  in  how  far  an  attempt  to  distinguish 
their  seat  and  precise  nature  is  likely  to  succeed. 

The  presence  of  a  tumor  in  the  brain  is  rendered  probable  if, 
in  addition  to  vertigo,  to  vomiting  or  to  a  disposition  to  vomit,  or 
to  headache,  violent  but  paroxysmal  and  neuralgic  in  its  character, 
we  find  impairment  or  loss  of  vision,  or  indeed  aneesthesia  of  any 
special  sense,  and  epileptiform  convulsions  not  followed  by  any 
greater  deterioration  of  health  than  previously  existed ;  if  with 
these  signs  of  cerebral  irritation  the  intellect  is  not  at  first  markedly 
disordered,  nor  the  articulation  affected  ;  and  if  paralyses  do  not 
show  themselves  until  a  very  long  time  after  the  headache,  and  are 
even  then  limited  to  the  muscles  of  the  eyeball  or  of  the  face,  or 
to  the  muscles  of  the  extremities  of  one  side  of  the  body.  As  a 
further  sign  of  cerebral  tumor,  we  may  class  optic  neuritis,  or 
choked  disk.     It  is  a  curious  fact  to  be  borne  in  mind  that  cere- 

*  Archives  de  Physiologie,  March,  1873. 


214  MEDICAL    DIAGNOSIS. 

bral  tumors  occur  in  males  more  tlian  twice  as  frequently  as  in 
females.-  It  may  also  be  noted  that  the  larger  number  of  cases 
are  in  the  young  or  in  the  prime  of  life ;  the  aged  are  remarkably 
exempt.  Yet  before  the  evidence  is  considered  conclusive,  we 
must  exclude  other  chronic  cerebral  maladies,  especially  softening, 
abscesses,  and  chronic  meningitis. 

AVe  separate  softening  by  noticing  that  the  headache  caused  by 
a  tumor  is  much  more  violent  and  paroxysmal,  not  dull  or  of 
steady  intensity ;  that  the  intelligence  remains  for  a  long  time 
intact,  save,  perhaps,  in  a  weakening  of  the  memory ;  that  motor 
and  sensory  disturbances  are  less  frequent  and  prominent,  but 
convulsions  far  more  so.  Remissions,  or  intervals  of  apparent 
improvement,  occur  in  both  morbid  states ;  but  they  are  more 
perfect  and  of  longer  duration  in  tumor  than  in  softening.  And 
in  the  latter,  too,  we  often  have  the  signs  of  endocarditis  or  a 
valve-lesion  to  make  an  embolus  probable,  or  there  is  the  history 
of  constitutional  syphilis  or  of  Bright's  disease  with  diseased 
vessels. 

The  differential  diagnosis  between  tumor  and  abscess  is  more 
difficult.  We  may  conclude  the  latter  to  exist,  if  the 'cephalalgia 
be  sudden  in  its  development,  and  uniform  and  general,  instead 
of  neuralgic  and  limited.  Then,  convulsions,  drowsiness,  paral- 
ysis, and  coma  succeed  one  another  much  more  rapidly  and,  ex- 
cept convulsions,  are  present  much  more  constantly  in  abscess 
than  in  tumor, — a  malady  running  a  very  chronic  course,  and  in 
which  the  patient  does  not  remain  drowsy  or  palsied  after  the 
epileptiform  seizures.*  If,  moreover,  we  obtain  the  history  of 
injury  to  the  skull,  or  find  a  discharge  from  the  ear,  or  pain  upon 
pressure  over  the  mastoid  process,  or  a  chonic  disease  about  the 
head,  or  albuminous  urine,  or  protracted  suppuration  in  any  part 
of  the  body,  we  may  safely  infer  that  an  abscess,  not  a  tumor,  is 
the  cause  of  the  evident  cerebral  mischief. 

Chronic  meningitis,  an  affection  sometimes  complicating  tumor, 
is  discriminated  by  laying  stress  on  its  etiological  relations, — such 
as  blows  upon  the  head,  diseases  of  the  bones,  syphilis,  rheuma- 

*  With  reference  to  the  epileptic  fits,  they  may  be  absent.  Thus,  they  oc- 
currod  in  only  thirty-eight  cases  of  abscess  of  the  brain  out  of  seventy-three 
collected  by  Gull  and  Sutton  (see  article  "  Abscess  of  Brain,"  in  Reynolds's 
System  of  Medicine). 


DISEASES    OF   THE    BRAIN    AND    SPINAE   CORD.  215 

tism,  or  alcoholism, — and  by  observing  its  frequent  though  irregu- 
lar accessions  of  fever,  the  great  irritability  of  temper,  the  dulness 
of  intellect,  the  loss  of  memory,  and  the  nocturnal  delirium.  The 
pain,  too,  is,  as  a  rule,  someAvhat  duller  and  more  diffused  than  in 
tumor,  though  more  fixed  and  constant,  and  there  is  more  vertigo ; 
but  the  convulsions,  on  the  other  hand,  are  less  distinctly  epilep- 
tiform in  type ;  yet  convulsive  movements  of  some  muscles  arc 
very  common,  and  may  even  be  followed  by  incomplete  paralysis. 
Meningitis  may  be  excluded  if  optic  neuritis  or  any  marked  al- 
teration of  the  disks  be  found  early  in  the  case.  Indeed,  optic 
neuritis  is  mostly  absent  or  is  very  slight  in  chronic  meningitis.  , 
Thrombosis  of  the  sinuses  of  the  brain  may  occasion  partial  pal- 
sies, and  the  symptoms  of  cerebral  pressure,  like  those  of  tumors, 
and  cannot  be  distinguished  except  in  those  instances  in  which 
we  can  find  distention  of  the  collateral  circulation  and  injection 
and- oedema  of  the  forehead  and  eyelids.*  Convulsions,  further, 
are  very  rarely  among  the  symptoms ;  and  generally  these  are 
more  similar  to  the  manifestations  of  meningitis  than  of  tumor. 
In  children  with  marasmus  or  in  adults  with  caries  of  the  skull 
marked  cerebral  phenomena  may  lead  to  the  correct  inference  of 
thrombosis. 

The  precise  seat  of  the  tumor  it  is  very  difficult  to  determine. 
An  affection  of  the  special  senses  points  to  disease  near  to,  or  at, 
the  base  of  the  brain ;  and  the  probability  of  this  view  is  much 
strengthened  if  there  be  paralysis  of  the  face  on  the  side  opposite 
to  that  of  the  extremities,  and  if  vigorous  inspiration,  during 
which  the  brain  falls  and  presses  the  morbid  mass  against  the 
walls  of  the  base  of  the  skull,  cause  or  increase  pain ;  whereas,  so 
says  Romberg,  in  tumors  on  the  upper  surface,  forced  expiration 
produces  a  like  result.  In  cases  of  tumor  of  the  pons  or  the  cms, 
particularly  when  tubercular,  incoordination  of  the  arm  similar 
to  the  jerky  movement  of  disseminated  sclerosis  is  met  with  ;  but 
it  is  unilateral,  not  bilateral  as  in  sclerosis.  In  tumors  of  the 
cerebellum  we  have  headache,  severe,  often  bilious  vomiting,  nys- 
tagmus, staggering  gait,  also  spasms,  and  rigidity ;  the  knee-jerk 
may  be  absent  or  increased ;  there  may  be  no  marked  alteration 
of  the  disks.     Tumor  in  the  cortex  of  the  left  side  of  the  brain 

*  Heubner,  quoted  iu  Schmidfs  Jalirbiicher,  No.  1,  1869. 


216  MEDICAL    DIAGNOSIS. 

lias  been  observed  to  give  rise  to  localized  convulsions,  beginning 
in  the  right  foot.*  Then  as  regards  the  exact  position  of  brain 
tumors  Me  must  bear  in  mind  the  localization  of  the  cerebral 
functions,  which  recent  research  is  elucidating  for  us.  The  diffi- 
culty of  applying  this  extending  knowledge  to  the  diagnosis  of 
tumors  at  the  bedside  is  that  they  may  give  rise  to  circumscribed 
inflammation  around  them,  or  to  irritation  in  even  somewhat  more 
remote  parts,  and  that  the  special  manifestations  of  the  disorder 
of  the  part  aifected  by  the  tumor  are  thus  blurred  or  obscured. f 

In  endeavoring  to  determine  the  seat  of  the  tumor  it  is  neces- 
sary to  distinguish  as  clearly  as  possible  the  difference  between 
the  results  of  generalized  pressure  or  distant  effects  and  those 
due  to  direct  and  localized  influences.  It  is  only  the  constant 
abnormal  symptom  that  points  out  the  location  of  the  lesion. 
Paralyses,  pareses,  spasms,  which  change  in  intensity  or  affect 
now  one,  now  another  set  of  muscles  or  organs,  show  that  the 
centres  are  disordered  only  indirectly  and  temporarily,  and  that 
the  true  position  of  the  neoplasm  is  to  be  sought  elsewhere.  An- 
other indication  is  derived  from  a  consideration  of  the  relative 
intensity  of  the  different  symptoms.  The  less  complete  a  paral- 
ysis or  the  less  energetic  the  spasm  of  a  certain  set  of  muscles,  the 
less  certain  is  the  injury  to  be  localized  in  their  centres,  and  the 
reverse.  Too  much  dependence  must  not  be  placed  on  the  subjec- 
tive location  of  the  pain.  Diffuse  pressure  may  cause  more  pain 
at  a  point  far  removed  from  the  growth  than  in  its  immediate 
neighborhood.  But  when  spasm  or  paralysis  of  a  limited  set 
of  muscles  exists,  as  in  cortical  epilepsy,  and  the  pain  is  located 
by  the  patient  at  a  point  corresponding  to  the  topographical  posi- 
tion of  the  corresponding  centres,  the  deduction  becomes  quite 
certain  that  the  lesion  is  at  this  point.  When  from  other  indica- 
tions the  inference  is  probable  that  the  growth  is  in  the  cortical 
substance,  the  additional  symptom  of  pain  makes  the  diagnosis 
more  sure.  Yet  another  indication  of  location  is  gained  when 
it  is  found  that  the  symptoms  are  more  narrowly  limited  either 
in  extent  or  in  kind.     The  more  diffuse  and  general  the  symp- 


*  Hughlings  Jackson,  Brain,  1882,  p.  364. 

•f-  Compare  Nothnagel,  op.  cit,  and  Bernhard,  Symptomatologie  und  Diag- 
nostik  der  Gehirngeschwiilste,  Berlin,  1881. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  217 

toms,  the  more  difficult  it  is  to  judge  what  part  is  affected.  It 
follows,  moreover,  that  in  all  tumors  of  the  cortex,  or  of  the  white 
substance  immediately  beneath,  the  symptoms  will  be  unilateral. 
When  both  sides  of  the  body  are  about  equally  affected,  the  tumor 
must  almost  necessarily  be  placed  at  the  base  of  the  brain.  Where 
the  symptoms  are  more  intense  upon  one  side  of  the  body  than 
upon  the  other,  the  weaker  symptoms  are  to  be  attributed  to  the 
distant  or  indirect  effects  of  pressure.  Paralysis,  of  course,  is  a 
more  severe  symptom  than  spasm  or  convulsional  movement. 
The  last  is  therefore  probably  due  to  an  irritational  or  indirect 
effect,  or  to  a  slowly-growing  neoplasm.  The  existence  of  papil- 
litis {optic  neuritis,  or  choked  disk)  is  an  almost  certain  sign  of 
intracranial  neoplasm.  But,  unfortunately,  the  symptom  gives 
almost  no  indication  either  of  the  nature  or  of  the  seat  of  the 
new  growth.  Yet  since  the  papillitis  may  precede  other  symp- 
toms, and  since  also  no  deterioration  of  vision  may  have  been 
noticed  by  the  patient,  it  follows  that  an  ophthalmoscopic  ex- 
amination should  always  be  made  w^ien  there  is  any  suspicion 
of  the  existence  of  tumor. 

Can  we  form  an  opinion  of  the  nature  of  a  tumor  of  the  brain 
from  any  of  the  signs  referable  to  the  cerebral  malady?  We 
cannot :  the  character  of  the  pain  has  been  thonght  to  be  of  great 
significance ;  but  the  testimony  to  prove  that  it  is  so,  is  in  the 
highest  degree  unsatisfactory.  We  may  sometimes,  however,  from 
the  history  of  the  case,  or  from  the  existence  of  some  of  the 
manifestations  of  special  cachexia,  draw  a  correct  inference.  In 
gliomatous  brain  tumors,  Virchow  has  pointed  out,  there  is  often 
the  history  of  a  blow,  and,  like  tubercle,  they  are  apt  to  occur 
in  the  cerebellum.  If  we  find  disease  of  the  lungs,  or  any  evi- 
dences of  scrofula,  and  the  patient  is  young,  we  shall  probably 
be  right  in  conjecturing  the  tumor  of  the  brain  to  be  a  mass  of 
tubercle;  but  if  the  sufferer  is  advanced  in  years,  and  exhibits 
tumors  in  various  parts  of  the  body,  or  other  signs  of  a  cancer- 
ous diathesis,  we  may  with  reasonable  certainty  presume  the  tumor 
within  the  skull  to  be  cancerous.  Syphilitic  tumors  are  mostly 
cortical,  very  rarely  cerebellar,  grow  rapidly,  and  are  greatly  in- 
fluenced by  antisyphilitic  treatment.  Other  kinds  of  tumors  and 
deposits  can  scarcely  be  said  to  be  within  the  reach  of  diagnosis. 
Cysts  seated  in  the  superficial  portions  of  the  brain  either  occasion 


218  MEDICAL   DIAGNOSIS. 

no  symptoms,  or  give  rise  to  headache,  to  attacks  of  vertigo,  to 
vomiting,  and  to  epileptic  seizures,  but  very  rarely  to  palsies. 
The  symptoms  mentioned  are  far  more  a[)t  to  be  present  when 
the  cysts  occupy  the  lateral  ventricles;  then  epileptic  convulsions 
esijccially  are  rarely  absent. 

The  symptoms  of  an  aneurism  within  the  cranium  are  those  of 
an  ordinary  tumor,  and  the  affection  is  not  distinguishable  except 
when  we  iind  decided  indications  of  disease  of  the  vessels  in  other 
parts  of  the  system.*  Neither  the  presence  nor  the  absence  of  a 
subjective  feeling  of  pulsation  and  of  a  murmur  has  a  positive 
significance  ;  for,  notwithstanding  the  cases  of  Jonathan  Hutchin- 
son f  and  Humble,!  in  which  the  diagnosis  was  made  during  life, 
the  detection  of  a  murmur,  as  I  know  from  observation,  is  not  a 
certain  sign.  In  aneurism  of  the  vertebral  arteries  epilepsy  is  a 
constant  symptom. § 

General  Paralysis. — This  fatal  cerebral  malady  is  a  diffuse 
interstitial  encephalitis  of  the  cortex  of  the  brain  ;  the  spinal 
cord  may  become  secondarily  affected.  Clinically,  the  disorder 
is  marked  by  impairment  of  the  powers  of  locomotion ;  by  an 
inability  to  articulate  distinctly, — a  symptom  which  precedes  the 
deranged  locomotion  ;  by  the  meaningless  countenance ;  and  by 
failure  of  memory  and  complete  perversion  of  the  mental  faculties, 
amounting,  in  fact,  to  insanity. 

The  palsy  is  peculiar :  indeed,  except  toward  the  end  there  is, 
in  the  usual  sense  of  the  term,  no  j)alsy  in  the  limbs  at  all ; 
there  is  rather  a  want  of  control  over  their  co-ordinate  action, 
displaying  itself  first  in  the  hands  by  clumsiness  of  movements 
and  irregular  handwriting,  and  in  the  gait  by  uncertainty  and  a 
swaying  from  side  to  side  when  the  patient  attem2)ts  to  ^v'alk. 
The  impairment  of  the  muscular  movement  gradually  extends : 
tremulousness  in  the  muscles  of  expression  is  noticed ;  the  speech 
becomes  more  inarticulate,  until  scarcely  a  word  can  be  dis- 
tinguished ;  and  the  patient  cannot  rise  without  being  assisted. 
As  the  disease  advances,  the  cutaneous  sensibility  is  greatly  dimin- 
ished or  is  lost.     The  pupils  are  unequal,  and  either  markedly 

*  .Tames  H.  Hutchinson,  Pennsj'lvania  Hospital  Eeports,  vol.  ii. 

t  British  Medical  .Journal,  April,  1875. 

%  London  Lancet,  Oct.  1875. 

2  Bartholow,  American  Journal  of  the  Medical  Sciences,  Oct.  1872. 


DISEASES    OF   THE    BRAIN    AND    SPINAL    CORD.  219 

dilated  or  contracted.  The  mental  derangement  is  generally 
marked  by  an  exaggerated  sense  of  personal  power  or  impor- 
tance, and  fancies  of  great  wealth  ;  the  moral  feelings  greatly 
deteriorate ;  sometimes  there  are  maniacal  outbreaks  and  (epilep- 
tic attacks,  or  alternating  periods  of  excitement  and  depression. 
Death  is  often  preceded  by  convulsive  attacks  and  by  coma,  or 
by  painful  contractions  of  the  muscles  of  the  trunk  or  the  ex- 
tremities, or  by  obstinate  diarrhoea,  or  by  pulmonary  aifections. 
Pneumonia  is  especially  common.* 

The  early  signs  of  general  paralysis  of  the  insane  are  difficult 
to  recognize.  A  change  in  character,  in  power  of  mental  attention, 
and  in  judgment,  absent-mindedness,  and  weariness  easily  brought 
on  by  brain-work  or  by  any  physical  exertion,  are  very  significant 
in  a  middle-aged  man,  if  joined  to  alteration  in  handwriting 
and  some  impairment  in  executing  delicate  muscular  movements. 
With  these  symptoms  there  is  commonly,  as  Fulsom  f  mentions, 
loss  of  flesh. 

In  more  advanced  stages  there  is  not  much  doubt  about  the 
malady.  It  differs  from  other  forms  of  extensive  general  paral- 
ysis in  being  far  less  of  a  real  palsy.  It  is  certainly  far  less 
complete  than  the  extensive  paralyses  which  follow  lesions  of 
the  upper  portion  of  the  spinal  cord,  or  which  are  consequent  upon 
the  poison  of  lead,  or  of  malaria,  or  of  diphtheria.  Its  association 
with  marked  disturbance  of  the  intellect  furnishes,  moreover,  a 
differential  test  of  great  value,  and  not  merely  with  reference  to 
the  general  palsies  just  mentioned,  but  also  as  regards  the  trem- 
bling movements  of  old  age,  of  progressive  muscular  atrophy,  and 
of  chronic  alcoholism.  In  one  of  its  forms,  as  Westphal  mentions, 
there  is  a  strong  resemblance  to  locomotor  ataxia  in  the  signs  of 
disturbed  co-ordination,  with  incontinence  of  urine  and  amaurosis  ; 
but  the  tremor  in  the  muscles  of  the  lips  and  face  and  the  per- 
verted mental  state  become  of  greatest  significance.  On  the  other 
hand,  the  ataxia  and  the  palsies  distinguish  the  disease  from  mere 
senile  dementia.  Then,  too,  dementia  paralytica  is  a  disease  of 
early  manhood  and  of  middle  age,  and  often  follows  alcoholism 
and  sexual  excesses. 


*  Crichton  Browne,  Brain,  Oct.  1883. 

-j-  Transact,  of  Association  of  American  Phj'sicians,  1889. 


220  MEDICAL    DIAGNOSIS. 

The  defect  in  the  articulation  and  the  attending  tremor  of  the 
lips,  and  in  some  instances  the  occurrence  of  apoplectiform  seizures, 
accompanied  by  considerable  elevation  of  temperature,  may  cause 
the  disease  to  be  mistaken  for  cerebrospinal  sclerosis.  But  in 
this  affection,  while  the  embarrassed,  scanning  speech  coexists 
with  great  helplessness  of  manner,  with  oscillation  of  the  eyeballs, 
with  tremor  manifesting  itself  only  on  motion,  with  paresis  of 
the  lower  limbs,  and  finally  with  permanent  contractions,  we  do 
not  notice  decided  alienation  of  mind  ;  there  is  nothino;  more 
than  general  enfeeblemcnt  and  blunted  emotional  faculties. 

Paralysis  ayitans  may  be  confounded  with  general  paralysis  of 
the  insane.  But  in  paralysis  agitans  the  voice  is  not  really  tremu- 
lous ;  there  is  rather  a  monotonous  tone  and  uncertain  uttci'ance, 
-which,  with  the  fixed  features,  the  sensation  of  excessive  heat,  the 
peculiar  gait  and  attitude,  the  unaltered  cutaneous  sensibility,  the 
tremor  ever  present  except  during  sleep,  the  manner  in  which  the 
patient  when  attempting  to  walk  is  propelled  forward,  and  the 
very  long  duration  of  the  symptoms,  characterize  the  disease. 
The  intellect  becomes  obscured  toAvard  the  end  of  the  malady,  but 
not  before.  The  cases  most  difficult  to  distinguish  are  those  ex- 
ceptional ones  of  general  paralysis  with  altered  character  and  en- 
feeblemcnt of  intelligence  but  without  insanity,  and  in  which  the 
motor  disorders  are  apt  to  be  very  pronounced. 

Diseases  characterized  by  Enlargement  of  the  Head. 

Chronic  Hydrocephalus. — The  signs  of  dropsy  of  the  brain 
are,  progressive  enlargement  of  the  head,  and  a  perversion  or  a 
gradual  loss  of  one  or  several  of  the  special  senses,  of  the  mental 
faculties,  and  of  the  power  of  voluntary  motion.  The  child  can- 
not bear  the  weight  of  the  head  ;  the  gait  is  tottering  and  uncer- 
tain. The  intellect,  slowly  but  certainly,  becomes  deranged.  As 
the  malady  advances,  strabismus,  partial  palsies,  epileptic  convul- 
sions, vomiting,  cutaneous  ana?sthesia,  and  loss  of  sight,  of  smell, 
and  of  taste,  are  observable  ;  the  bowels  become  very  constipated  ; 
and  a  copious  secretion  of  tears  and  of  saliva  is  not  infrequent. 

Before  death  takes  place,  which  sometimes  does  not  happen  for 
years,  the  child  ordinarily  becomes  idiotic.  A  few  cases  recover ; 
fewer  reach  adult  age  with  their  brain  compressed  by  the  accumu- 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  221 

lated  fluid ;  in  still  fewer  the  disease  docs  not  develop  itself  until 
after  childhood.  If  the  patient  survive  until  adult  age,  the  size 
of  the  skull  is  generally  immense.  I  saw,  some  years  since,  a 
young  man,  twenty-two  years  of  age,  whose  head  measured  fully 
two  feet  and  a  half  in  circumference.  He  could  walk  unaided, 
but  often  fell.  He  was  half  idiotic,  and  subject  to  epileptic  fits ; 
yet  he  had  sufficient  intelligence  to  understand  what  was  said  to 
him,  and  in  his  childish  way  to  do  as  he  was  told. 

The  skull  is  sometimes  very  large  without  dropsy  of  the  brain 
existing.  The  cranial  bones  may  slowly  thicken  to  an  extraor- 
dinary degree  from  syphilis,  or  from  unknown  causes.  The  head 
may  be  overgrown,  and  its  bones  thickened  and  spongy,  as  in 
rachitis;  or  it  may  be  large  when  there  is  no  disease.  These 
states  differ  from  chronic  hydrocephalus  by  the  absence  of  cerebral 
symptoms;  and  in  doubtful  cases  we  may  call  in  the  ophthalmo- 
scope as  a  means  of  diagnosis.  The  vessels  of  the  eye,  even  in 
the  early  stages  of  chronic  hydrocephalus,  enlarge,  and  in  pro- 
portion as  the  serum  compresses  the  brain  we  find  an  increase  of 
vascularity  in  the  retina,  with  dilatation  of  its  veins,  and  with 
an  increase  of  the  number  of  its  vessels  ;  complete  or  partial 
serons  infiltration  of  the  retina ;  and  an  atrophy,  more  or  less 
perceptible,  of  the  optic  nerve.  These  lesions  vary  with  the  age 
of  the  disease  and  the  amount  of  serous  effusion ;  but  none  of 
them  exist  in  rickets.*  Then  in  rickets  the  tendency  is  to  spasm 
of  the  glottis,  to  diarrhoea, — not,  as  in  hydrocephalus,  to  consti- 
pation. The  size  of  the  head  may  also  be  augmented  in  conse- 
quence of  meningeal  apoplexy,  or  of  hypertrophy  of  the  brain. 
The  former  may  be  suspected  if  the  distention  of  the  cranium 
follow,  at  no  very  long  interval,  an  attack  of  convulsions  and  of 
coma  in  a  teething  child. 

Hypertrophy  of  the  Erain. — A  complaint  in  which  the 
brain  develops  with  a  rapidity  disproportionate  to  the  growth  of 
its  bony  case,  which  thus  becomes  too  small  for  its  contents. 

The  symptoms  this  morbid  state  occasions  are  very  uncertain ; 
but,  irrespective  of  the  enlargement  of  the  head,  headache,  vertigo, 
drowsiness,  and  epileptiform  convulsions  have  been  observed.  The 
gait  is  very  unsteady  ;  the  mind  gradually  gives  way.     After  the 

*  Bouchut,  0}).  cit. 


222  MEDICAL    DIAGNOSIS. 

paroxysms  of  headache  and  of  convulsions  we  often  find  stupor, 
which  may  deepen  into  fatal  coma.  Sometimes  delirium,  or  even 
mania,  is  noticed.  There  are  palsies  vai-ying  according  to  the 
centres  pressed  on.  The  action  of  the  heart  is  apt  to  be  slow  and 
irregular ;  the  pulse  is  full  or  tense  ;  the  pupils  are  at  first  con- 
tracted, then  dilated  and  sluggish,  the  ophthalmoscope  shows 
swelling  of  the  papilla  or  optic  neuritis,  with  tortuous  full  veins. 
Death  is  occasionally  preceded  by  symptoms  of  meningitis  of  the 
convexities.  The  disease  is  apt  to  show  itself  in  early  cliildliood 
in  connection  with  rickets ;  it  has  also  been  observed  to  run  in 
families,* 

Hypertrophy  of  the  brain  requires  to  be  carefully  distinguished 
from  the  enlargement  of  the  head  which  takes  place  when  both 
the  brain  and  the  skull  increase  rapidly ;  an  hypertrophy  too,  in 
a  certain  sense,  but  not  an  hypertrophy  fraught  Math  danger  or 
occasioning  any  morbid  manifestations. 

Equally  important  is  it  to  discriminate  between  the  augmented 
brain  and  chronic  hydrocephalus.  Unfortunately,  the  marks  of 
distinction  are  not  very  clearly  traced.  Both  diseases  have  much 
the  same  symptoms ;  both  are  generally  of  long  duration.  There 
is,  however,  in  many  cases,  this  dissimilitude  :  in  hypertrophy  the 
convulsions  are  a  much  more  marked  phenomenon,  and  they  pre- 
cede, rather  than  accompany,  the  signs  of  failing  intellect  and  of 
cerebral  pressure.  The  changes  in  the  special  senses  are  not  so 
common,  or  so  prominent ;  there  is  not,  when  the  fontanels  are 
touched,  the  sensation  of  a  tense  membrane  filled  with  water,  but 
rather  of  a  solid  substance ;  and  the  body  does  not  waste  as  in 
dropsy  of  the  brain.  Mauthnerf  lays  great  stress  on  the  different 
shapes  of  the  head.  In  chronic  hydrocephalus,  he  states,  the 
forehead  is  the  first  to  enlarge,  and  the  posterior  part  of  the  skull 
does  not  expand  until  long  afterward  ;  in  hypertrophy  the  reverse 
takes  place.  But  this  is  of  questionable  value.  West  maintains 
that  in  hypertrophy  there  is  no  prominence,  but  an  actual  depres- 
sion, of  the  anterior  fontanel,  and  that  a  similar  depression  is 
observable  at  all  the  sutures. 

*  See  case  of  D'Espine,  quoted  in  Schmidt's  Jahrb.,  No.  3,  1882. 
t  Krankheiten  des  Gehirns,  etc  ,  Vienna,  1844. 


DISEASES    OF    THE    BRAIN    AND    SPINAL   CORD.  223 

Diseases  characterized  by  Paroxysmal  Pain. 

There  is  a  group  of  nervous  disorders  characterized  solely  by 
pain,  confined  ordinarily  to  one  nerve.  These  nervous  pains  bear 
tlie  generic  name  of  neuralgia.  Indeed,  in  all  neuralgias  the  chief 
symptoms  of  the  disorder  resolve  themselves  into  one  symptom, — 
the  symptom  of  pain.  The  pains  are  acute,  follow  the  course  of  a 
nervous  branch,  and  come  on  in  paroxysms  having  distinct  ex- 
acerbations, succeeded  by  distinct  intermissions.  In  some  cases 
these  intermissions  are  long,  in  others  short ;  in  some  they  are 
complete,  in  others  the  pain  is  lasting  and  becomes  from  time  to 
time  exalted, — rather  remissions,  therefore,  than  intermissions. 
Save  in  the  rarest  instances,  the  excruciating  sensations  are  not 
complicated  with  heat  and  swelling.  Nor  is  there  tenderness,  ex- 
cept when  the  neuralgia  is  of  long  continuance ;  at  least  there  is 
not  tenderness  along  the  aching  nerve,  though  we  may  find  certain 
sensitive  spots,  which,  in  the  case  of  the  spinal  nerves,  are  readily 
detected  by  pressing  on,  or  to  one  side  of,  the  spinous  process 
of  the  vertebra  near  which  the  affected  nerve  emerges,  and  by 
examining  the  points  of  terminal  expansion. 

The  pain  of  neuralgia  is,  then,  of  a  purely  nervous  character, 
and  exists  independently  of  inflammation,  or  of  any  recognizable 
textural  change  of  the  nervous  centres  or  nervous  trunks.  All 
fixed  pain  and  persistent  early  tenderness  and  evidences  of  trophic 
changes  in  the  skin  or  muscles,  and  cutaneous  eruptions  in  the 
course  of  the  affected  nerve,  bespeak  neuritis,  and  not  neuralgia ; 
and  it  is  only  when,  after  a  minute  search,  we  can  detect  no 
definite  organic  cause  for  the  local  pain,  that  we  may  set  down 
our  patient  as  laboring  under  neuralgia. 

From  the  characteristics  of  the  pain  just  mentioned,  it  is  evi- 
dent that  it  is  not  likely  to  be  confounded  with  that  of  ordinary 
local  inflammation.  But  there  is  a  kind  of  local  pain  for  which 
neuralgia  is  often  mistaken  :  the  pain  of  subacute  or  of  chronic 
rheumatism.  Yet  this  is  in  reality  very  dissimilar.  The  rheu- 
matic pain  is  attended  with  soreness,  is  aggravated  by  movement 
or  by  pressure,  is  more  diffuse  and  irregular,  much  more  constant, 
much  more  influenced  by  alternations  of  temperature,  but  not 
acute  or  paroxysmal,  and,  finally,  not  limited  anatomically  to  the 
course  of  one  nerve,  but  scattered  over  parts  supplied  by  several. 


224  >[EDICAL    DIAGNOSIS. 

Except  the  influence  of  the  weatlier,  the  pain  of  myalgia  presents 
much  the  same  points  of  difference,  in  addition  often  to  the  history 
of  a  muscular  strain. 

The  source  of  the  neuralgia  should  always  be  determined  as 
closely  as  possible,  on  account  both  of  the  prognosis  and  of  the 
treatment.  In  many  cases  it  Avill  be  found  to  be  connected  with 
anoemia  ;  in  others,  with  the  poison  of  rheumatism,  of  lithsemia  or 
gout,  of  malaria,  of  syphilis,  or  of  uraemia,  or  to  be  due  to  inju- 
ries to  nerves,  by  contusion  or  wounds.  It  is  often  reflex,  the 
pain  being  far  away  from  the  seat  of  the  disease,  and  due  to  irri- 
tation reflected  through  the  nervous  centres.  For  instance,  an 
affection  of  the  digestive  apparatus,  of  the  liver,  or  of  the  kidneys, 
may  give  rise  to  neuralgia  in  parts  quite  remote  from  them.  It 
is  evident  that  if  such  be  the  origin  of  the  disorder,  and  if  the 
malady  which  lies  at  its  root  and  excites  it  can  be  controlled,  the 
neuralgia  will  simultaneously  disappear.  Yet  it  must  be  confessed 
that  we  cannot  always  detect  the  cause,  whether  or  not  it  be  of  the 
nature  just  mentioned,  and  we  have  often  to  treat  the  neuralgia  by 
employing  those  agents  which  are  suitable  to  the  greatest  number 
of  cases. 

IS^euralgia  may  occur  in  any  portion  of  the  body.  It  may  shift 
rapidly  from  one  part  to  another,  as  in  that  peculiar  neuralgia  de- 
scribed by  Putegnat,*  excited  by  a  desire  to  pass  ^\ixiev  and  by  the 
act  of  micturition,  beginning  with  numbness  and  acute  burning 
or  lancinating  pain  along  the  urinary  passages,  then  aftccting 
particularly  the  nerves  of  the  forearm,  especially  the  ulnar,  and 
disappearing  completely  after  micturition.  The  most  frequent 
seat  of  neuralgia  is  about  the  head ;  and  we  shall  here  notice 
chiefly  a  few  of  its  most  common  kinds.  Most  of  the  other  vari- 
eties of  the  disorder  will  be  elsewhere  alluded  to. 

Neuralgia  long  continued  becomes  associated  with  the  signs  of 
nervous  weakness,  so-called  neurasthenia.  Indeed,  in  this  state 
neuralgic  symptoms  are  common,  as  are  also  abnormal  sensations 
in  the  head,  and  many  hysterical  manifestations.  Hysteria  is,  in 
truth,  interwoven  with  most  of  the  marked  cases  in  women ;  and 
the  history  of  excesses  or  of  great  mental  or  bodily  strain  usually 
accompanies  the  disorder  in  men. 

*  Gazette  Hebdoni.  de  Med.  et  Chir.,  April,  1864. 


DISEASES   OF   THE    BRAIN    AND   SPINAL    COED.  225 

Facial  Neuralgia. — The  facial  branches  of  the  fifth  pair  are 
often  the  site  of  agonizing  pain.  But  all  the  branches  of  the  nerve 
are  not  equally  liable  :  the  lowermost  of  them  is  rarely  affected. 
When  the  supra-orbital  division  is  the  seat  of  the  ailment,  the 
pain  shoots  to  the  forehead,  the  eyebrow,  and  the  eyeball,  which  is 
apt  to  become  injected.  If  the  infra-orbital  nerve  be  disturl^ed, 
the  pain  darts  to  the  upper  lip,  to  the  upper  row  of  teeth  and  the 
posterior  nares,  and  the  cheek  reddens  and  tingles,  or  the  eyelids 
twitch.  When  the  pain  occurs  in  the  inferior  branch,  it  radiates 
to  the  lower  lip  and  the  chin,  and  is  frequently  accompanied  by  a 
flow  of  saliva.  Generally  the  parts  around  the  point  where  the 
affected  nerve  emerges  are  sensitive  to  the  slightest  touch.  Some- 
times only  one,  at  other  times  two,  at  other  times  all  of  the 
branches  of  the  fifth  are  implicated  in  the  complaint,  or  they 
may  be  seized  upon  alternately.  There  is  often  also  pain  at  the 
vortex. 

The  disease  is  one  of  those  belonging  to  advancing  years ;  one 
of  the  neuralgias  of  bodily  decay  on  which  Anstie  dwells.  It 
has  the  same  general  causes  as  any  other  form  of  neuralgia. 
Sometimes  it  is  associated  with  decayed  teeth,  or  with  an  ab- 
normal state  of  the  bones  of  the  head  or  face,  such  as  thicken- 
ing of  the  frontal,  ethmoid,  and  sphenoid  bones.  Many  of  these 
cases  terminate,  after  months  or  years  of  excruciating  agony,  in 
apoplexy.*  AVhen  from  decayed  teeth,  the  pain  finally  localizes 
itself  in  the  dental  arch,  and  there  is  persistent  discomfort  in 
addition  to  the  neuralgic  exacerbations. f 

The  intervals  between  the  paroxysms  of  neuralgia  are  of  vary- 
ing length.  They  may  be  of  six  months',  or  even  a  year's,  dura- 
tion ;  but  so  long  an  intermission  is  uncommon.  Seasons  in 
which  sudden  changes  of  weather  are  frequent  generally  excite 
attacks. 

The  malady  is  easily  recognized.  It  may  be  mistaken  for,  or 
rather  there  may  be  mistaken  for  it,  a  disease  of  the  bones  of  the 
face.  But  the  local  signs  of  this  are  different,  and  the  pain  is  not 
paroxysmal.     Painful  ansedhesia  qfthefifih  nerve  is  discriminated 


*  Sir  Henry  Halford's  Essays  and  Orations,  p.  37  et  seq. 
t  An  interesting  collection  of  cases  is  given  in  an  essay  by  Dr.  Brubaker 
on  Eeflex  Neurosis  associated  with  Dental  Pathology. 

15 


226  MEDICAL   DIAGNOSIS. 

by  the  insensibility  of  the  painful  portions  to  touch,  or  indeed  to 
any  irritation.  Spavin  of  the  face  is  distinguished  by  the  abscnee 
of  pain,  from  the  convulsive  twitchings  of  reflex  origin  which 
sometimes  take  place  in  facial  neuralgia  or  "  tie  douloureux." 

The  epileptiform  neurak/ia  described  by  Trousseau  is  dissimilar 
in  these  peculiarities :  whether  simple  or  combined  with  rapid 
convulsive  movements  of  the  muscles  on  one  side  of  the  face,  it  is 
quickly  over ;  it  lasts  but  ten  or  twenty  seconds  at  a  time,  never 
more  than  a  minute.  Yet  during  the  short  duration  of  the 
seizures  the  pain  reaches  an  intensity  greater  than  in  ordinary 
neuralgia.  Moreover,  in  some  persons  who  suifer  from  this 
terrible  malady — the  attacks  of  which  may  happen  in  quick  suc- 
cession by  day  as  well  as  by  night,  and  then  perhaps  remit  for 
weeks  or  months — vertiginous  sensations  or  epileptic  fits  occur, 
and  thus  the  diagnosis  is  facilitated  by  the  history  of  the  case. 

Hemicrania. — The  pain  here  is  limited  to  the  supra-orbital 
and  temporal  regions  of  one  side,  but  it  may  extend  to  the  scalp 
and  be  double-sided.  The  pain  is  intensified  by  sound  of  any 
kind,  and  is  commonly  accompanied  by  disorder  of  sight,*  a 
numbness  and  tingling  in  the  limbs,  a  sense  of  weight,  and  sick- 
ness of  stomach  ;  the  nausea  and  vomiting  of  the  "  sick-headaclie" 
are  usually,  indeed,  prominent  features  of  the  paroxysm,  hardly 
less  prominent  than  the  pain.  The  attack  lasts  for  hours  or  days  ; 
often  it  is  severe  for  half  a  day.  At  its  termination,  the  patient 
feels  exhausted,  yet  soon  recovers  his  usual  health,  and  may 
remain  free  from  a  seizure  for  a  long  time.  But,  as  the  disorder 
most  commonly  occurs  in  women,  and  usually  at  their  menstrual 
periods,  the  interval  is  not  apt  to  extend  beyond  four  weeks. 

Hemicrania,  or  megrim,  has  been  explained  as  a  neurosis  of  the 
sympathetic ;  or  as  a  discharge  of  nerve-force,  a  "  nerve-storm," 
from  centric  disorder.  It  is  a  stubl^orn  affection,  the  tendency 
to  which  diminishes  after  middle  age,  but  which,  as  Liveingf 
clearly  demonstrates,  has  an  hereditary  character. 

*  There  may  be  obliteration  of  objects  in  the  field  of  view,  or  a  curious 
glimmering  attended  with  colored  outline  near  the  outside  comer  of  the  field 
of  vision.  These  ophthalmic  migraines  have  been  recently  described  by  Char- 
cot (vol.  iii.  of  his  Clinical  Lectures)  as  being  at  times  among  the  forerunners 
of  general  paralysis. 

t  On  Megrim,  London,  1873. 


DISEASES   OF   THE   BRAIN   AND   SPINAL   CORD.  227 

Hemicrania  must  be  carefully  separated  from  the  pain  in  the 
head  which  accompanies  an  organic  cerebral  affection.  The  main 
points  of  distinction  are,  that  the  neuralgic  malady  is  paroxysmal, 
is  attended  with  the  same  group  of  symptoms  during  each  attack, 
and  produces  no  nervous  derangement  in  the  intervals  between 
the  seizures. 

Rheumatism  of  the  scalp  differs  from  hemicrania  in  the  pain 
being  continuous,  dull,  and  superficial ;  in  occupying  generally 
both  sides  of  the  head ;  in  being  augmented  by  moving  the 
affected  muscles,  and  relieved  by  warmth.  Moreover,  there  is 
almost  always  other  evidence  of  rheumatism,  and  the  pain  is 
intensified  by  pressure ;  whereas  in  hemicrania,  although  the  hair 
may  be  sensitive  to  the  touch,  strong  pressure  on  the  forehead, 
and  even  on  the  hairy  part  of  the  scalp,  does  not  increase  the 
pain,  may  indeed  afford  relief. 

In  periostitis  affecting  the  bones  of  the  head,  particularly  when 
syphilitic,  we  may  find  the  same  violent  pain  as  in  hemicrania. 
But  there  is  considerable  tenderness  on  pressure,  the  parts  attacked 
are  swollen  and  less  elastic  than  the  healthy  portions,  and  the  pain 
is  especially  severe  at  night. 

Sciatica. — This  is  neuralgia  following  the  course  of  the  sciatic 
nerve.  The  seat  of  the  greatest  suffering  is  generally  the  lateral 
surface  of  the  thigh ;  thence  the  pains  extend  to  the  popliteal 
space,  and  in  some  instances  along  the  anterior  part  of  the  leg. 
Often,  too,  the  patient  complains  of  an  aching  near  the  sciatic 
notch  and  in  the  loins.  The  pain  is  more  or  less  steady,  but 
it  has  its  periods  of  fierce  exacerbation ;  and  damp,  cold,  and 
pressure  augment  it.  Pressure  on  localized  points  always  de- 
velops pain,  and  the  points  that  are  most  marked  are  on  the 
lower  end  of  the  sacrum,  on  the  side  of  the  trochanter  opposite 
the  emergence  of  the  great  and  small  sciatic  nerves,  various 
points  on  the  posterior  aspect  of  the  thigh,  one  at  the  head  of 
the  fibula,  and  one  behind  the  outer  ankle. 

The  disease  is  obstinate,  and  lasts  for  weeks  or  months.  It  in- 
terferes with  locomotion,  because  of  the  distress  which  movements 
of  the  leg  and  foot  occasion.  It  is  a  very  rare  disease  in  children. 
Generally  it  depends  upon  exposure  to  cold,  or  upon  the  rheu- 
matic diathesis,  or  upon  a  neuralgic  predisposition,  or  upon  an 
irritation  affecting  the  nerve  before  it  leaves  the  pelvis,  the  result 


228  MEDICAL    DIAGXOSIS. 

not  unusually  of  sexual  disorder,  or  of  pressure  from  a  gravid 
Nvomb,  or  of  an  accumulation  of  fteccs  in  the  colon.  Iji  some 
instances  it  is  connected  \vith  gout,  in  others  with  anaemia,  with 
syphilis,  with  disease  of  the  hip-joints ;  and  it  may  be,  although 
it  very  rarely  is,  symptomatic  of  cerebral  disease.  Occasionally  it 
is  due  to  reflex  excitation  of  the  nerve.  Sometimes  it  occurs  after 
forced  marches  or  long  rides ;  probably  in  the  majority  of  these 
cases,  however,  the  sciatica  is  rheumatic.  It  is  seldom  double, 
except  when  of  diabetic  origin,  or  when  due  to  compression  from  a 
growing  tumor  in  the  pelvis  or  from  enlarging  cancerous  vertebrae. 

Sciatica,  when  of  long  duration,  leads  to  loss  of  motor  power 
in  the  leg,  to  tingling,  and  to  anresthesia ;  and  certain  nutritive 
changes  are  observed  in  the  limb,  which  is  found  to  have  de- 
cidedly dwindled.  In  many — probably  in  most — instances  the 
disorder  is  clearly  the  result  of  neuritis,  and  then  there  is  gener- 
ally more  tenderness, — in  truth,  in  pure  neuralgia  there  is  not 
much, — and  movement  and  position  have  but  little  influence  on 
it.  Then  tlie  history  of  the  case  in  pure  neuralgia,  the  frequent 
anaemia,  and  the  coexistence  with  other  neuralgias,  are  very  sig- 
nificant.    Occasionally  the  neuritis  ascends  to  the  cord. 

It  is  often  a  very  essential  matter  to  determine  whether  or  not 
an  effusion  has  taken  place  within  the  sheath  of  the  nerve.  In 
the  main,  what  Fuller  tells  us  is  correct,  that  the  presence  of  fluid 
within  the  nerve-sheath  may  be  inferred  when  a  patient  Avho  is 
suffering  from  sciatica  complains  of  a  dull  aching  or  a  benumb- 
ing pain  in  the  limb,  causing  it  to  feel  swollen,  and  when  this 
sense  of  numbness  and  increased  bulk  has  succeeded  to  })ain  of 
greater  intensity,  accompanied  by  cramps  and  startings  and  more 
or  less  inability  to  move  the  limb. 

The  disorders  which  are  most  likely  to  be  confounded  with 
sciatica  are  :  rheumatism  of  the  muscles  and  fibrous  sheaths  around 
the  hip-joint ;  affections  of  the  joint ;  and  pains  caused  by  irrita- 
tion of  the  kidney.  The  former  is  very  readily  distinguished. 
It  is  generally,  what  sciatica  is  rarely,  double-sided  ;  and  the 
pain  is  dull,  diffuse,  not  paroxysmal,  not  limited  to  the  sciatic 
nerve  and  its  area  of  distribution,  nor  as  much  increased  on 
pressure  as  that  of  sciatica.  But,  practically  speaking,  this  kind 
of  rheumatism  is  seldom  seen  unless  associated  with  rheumatic 
neuritis  of  the  sciatic  nerve. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  220 

In  affections  of  the  hip-joint  the  suffering  is  increased  by  stand- 
ing with  the  weight  of"  the  body  thrown  on  the  diseased  leg. 
Moreover,  the  pain  is  usually  limited  to  the  hip-  and  knee-joints ; 
does  not  descend  in  the  course  of  the  sciatic ;  is  not  associated  with 
tenderness  of  the  nerve ;  the  aspect  of  the  limb  points  to  the  dis- 
organization that  is  going  on ;  the  leg  shortens.  Yet,  before  ad- 
mitting this  as  a  mark  of  difference,  it  must  be  ascertained  by 
careful  measurement ;  for,  in  consequence  of  muscular  contrac- 
tions, the  affected  limb  in  sciatica  may  appear  to  be  shorter  than 
it  is.  The  main  points  of  distinction  between  sciatica  and  a 
nervous  affection  of  the  hip-joint  are  the  usual  combination  of 
the  latter  with  hysteria,  the  very  superficial  tenderness,  and  the 
fact  that  the  pain  is  apt  to  extend  over  the  whole  thigh. 

Irritation  of  the  Iddney  causes  pain  shooting  down  the  thigh. 
The  distress  exists,  however,  in  the  course  of  the  anterior  crural 
nerve,  is  therefore  not  localized  in  the  sciatic,  is  unattended  with 
tenderness,  but  is  accompanied  by  a  frequent  desire  to  pass  water, 
and  by  other  signs  of  disorder  of  the  urinary  functions. 

Sciatica  is  sometimes  feigned,  especially  by  soldiers.  But  the 
copy  is  rarely  a  very  accurate  one.  Impostors  complain  of  pain 
on  pressure  and  on  motion,  but  are  ignorant  that  the  pain  is  prone 
to  exacerbate  after  intervals  of  comparative  quiet,  and  to  increase 
in  violence  as  night  approaches.  Their  fancied  torment  is  con- 
stant, but  does  not  prevent  them  from  sleeping ;  they  wince  when 
the  muscles  of  the  thigh  are  touched,  yet,  if  their  attention  be 
diverted,  the  hand  may  be  pressed  along  the  sciatic  nerve  without 
any  sign  of  tenderness  being  manifested. 


CHAPTER  III. 

DISEASES   OF   THE   UPPEE   AIR-PASSAGES. 

The  larynx  and  trachea  form  the  main  portion  of  the  upper 
air-passages.  The  aifeetions  of  the  larynx  are  far  the  most  fre- 
quent. There  are  symptoms  in  laryngeal  diseases  M'hich  at  once 
direct  attention  to  the  seat  of  the  malady.  The  lar}'nx  is  the 
organ  of  speech  :  hence  changes  in  the  i-oice  constitute  the  most 
striking  manifestations  of  disorder.  These  changes  vary  in  degree. 
The  voice  may  be  merely  hoarse,  or  completely  lost.  In  young 
children  the  different  tone  of  the  cry  corresponds  to  the  altered 
voice  of  adults.  The  alteration  of  the  voice  depends  almost 
wholly  upon  an  affection  of  the  vocal  cords,  and  this  may  be 
organic,  such  as  inflammation,  oedema,  ulceration,  cicatrices,  aud 
morbid  growths ;  or  it  may  proceed  from  perverted  or  impaired 
innervation.  Very  often  the  hoarseness  or  loss  of  voice  is  caused 
by  diminished  tension  and  want  of  certain  and  prompt  action  of 
the  vocal  cords,  whether  connected  with  structural  change  or  not. 
The  same  cause  gives  rise,  for  the  most  part,  to  the  modifica- 
tions of  the  voice  which  show  themselves  as  huskiness  in  speak- 
ing, or  in  the  loss  of  certain  notes  in  singing. 

Next  to  the  voice  in  diagnostic  importance  stand  the  character 
of  the  breathing  and  the  cough.  The  breathing  is  labored  and 
difficult,  and  is  frequently  perceived  to  be  noisy,  and  coarse  or 
shrill, — the  so-called  laryngeal  stridor :  a  sign  encountered  when- 
ever the  orifice  through  which  the  air  has  to  pass  is  narrowed, 
either  temporarily  by  a  spasm,  or  more  permanently  by  an}'  state 
which  gives  rise  to  a  constriction  of  the  parts ;  for  instance,  by 
swelling  of  the  mucous  membrane. 

The  difficulty  in  breathing  is  in  some  diseases  slight;  in  others 
great.  One  of  the  peculiarities  of  this  laryngeal  d}-spnoea  is  its 
tendency  to  recur  in  paroxysms,  during  which  the  patient  appears 
230 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  231 

to  be  in  imminent  clanger  of  strangling.  These  fits  of  suffocation 
are  produced  mostly  by  a  spasm  of  the  glottis.  They  occur  in 
pure  spasm  of  the  glottis  ;  in  croup  ;  in  oedema  of  the  glottis ;  in 
ulceration  and  in  polypi  of  the  larynx. 

The  cough  of  laryngeal  affections  presents  frequently  the  same 
peculiarity  as  the  dyspnoea, — it  happens  in  paroxysms.  Another 
peculiarity,  although  not  one  so  constant,  is  its  harsh  and  ring- 
ing tone.  The  cough  is  often  short  and  dry ;  sometimes  it  is 
followed  by  a  muco-purulent  expectoration  of  roundish  shape,  or 
by  a  blood-streaked  sputum,  or  by  the  spitting  up  of  false  mem- 
brane. It  is  readily  excited  by  the  act  of  swallowing,  its  seat  is 
referred  by  the  patient  himself  to  the  windpipe,  and  it  is  apt  to  be 
especially  troublesome  at  night. 

Pain  is  not  so  usual  a  symptom  of  laryngeal  disease  as  either 
cough  or  changed  breathing.  In  chronic  affections  it  may  be, 
indeed,  wanting.  It  is  rarely  severe;  often  more  a  sensation  of 
tickling,  of  burning,  or  of  uneasiness  than  of  actual  pain.  It  is 
apt  to  extend  down  the  trachea  to  the  upper  part  of  the  sternum. 
Sometimes  it  is  increased  on  pressure,  as  in  acute  laryngitis  and 
in  ulceration  of  the  mucous  membrane ;  and  it  may  be  also  aug- 
mented by  the  act  of  swallowing. 

By  the  symptoms,  then,  of  altered  voice,  cough,  dyspnoea,  and, 
in  some  cases,  of  local  pain  and  difficulty  in  deglutition,  we  recog- 
nize a  laryngeal  affection ;  and  these  symptoms  reveal  more  than 
any  physical  examination  of  the  organ  made  by  the  means  ordi- 
narily in  use.  The  stethoscope  is  occasionally  of  service ;  yet,  on 
the  whole,  it  furnishes  little  information.  But  inspection  of  the 
larynx  has  been  rendered  practicable  by  the  aid  of  the  laryngo- 
scope, and  our  knowledge  of  laryngeal  diseases  has  been  revo- 
lutionized through  its  influence.  The  instrument  consists  of  a 
small  mirror  fixed  on  a  long  stem.  The  mirror  is  best  made 
of  glass  backed  with  silver.  It  may  be  either  circular,  square, 
or  oval.  The  circular  mirror  occasions  least  irritation.  It 
may  vary  in  size  from  half  an  inch  to  an  inch  and  a  quarter 
in  diameter.  The  larger  the  mirror  we  can  employ,  the  better 
is  the  image. 

The  mirror  is  in  some  cases  all  that  is  necessary  to  practise 
laryngoscopy.  It  is  heated  in  warm  water  or  over  a  lamp,  and 
then  introduced  into  the  back  of  the  mouth  in  the  manner  pres- 


232 


MEDICAL    DIAGNOSIS. 


ently  to  be  described  ;  the 
person  to  be  cxamiiKxl  having 
been  phioed  with  his  face  to- 
ward the  sunlight,  so  that  its 
rays  may  strike  the  laryngeal 
mirror. 

But  examinations  by  direct 
light  are  practicable  only  on 
some  days  and  at  certain  pe- 
riods of  the  day.    Usually  we 
require   a    second   mirror   to 
illuminate  the  throat  and  thc' 
laryngoscope.      This    mirror, 
when  sunlight  is   enn^loyed, 
has  a  plane  surface;  when  artificial  light 
is  used,  it  is  better  that  the  reflector  be 
slightly  concave.     One  of  circular  form, 
about  three  inches  and  a  half  in  diam- 
eter, and  with  a    focus  of  from  ten  to 
fourteen    inches,  answers  best.     It  may 
be  either  attached  to  the  head  by  means 
of  a  baud,  or  worn  on  a  pair  of  spectacle- 
frames,  or  placed  on  a  movable  stand,  or 
affixed  to  a  lamp,  or  fastened  to  a  handle 
which  is  held  in  the  mouth.     The  latter 
plan,  that  of  Czermak,  is  the  one  least 
employed :  it  is  far  less  convenient  than 
the  spectacle   attachment  introduced  by 
Semelcder.      AVhen    this   or    the    frontal 
band  is  made  use  of,  the  observer  may 
either  place  the  mirror  opposite  to  one  of 
his  eyes,  and  look  through   the  central 
perforation,  or  adopt  the  easier  method  of 
wearing  the  reflector  on  his  forehead. 

The  French  have  recourse  for  the  most 
part  to  lenses,  and  concentrate  the  light 
directly  into  the  throat.  But  a  better 
arrangement  is  obtained  in  Mackenzie's 
rack-movement  bracket  and  bull's-eye 
condenser  ;  or  bv  a  combination  of  lenses    i-arj-ngoscopes  of  various  shape ; 

'  •  not  quite  natiuiil  Mze. 


DISEASES    OF    THE    UPPER   AIR- PASSAGES. 


ooo 


attached  to  a  metallic  frame  which  is  fastened  to  a  lamp,  as  in  the 
well-known  apparatus  of  Tobold.  The  best  light  to  employ  is 
coal-oil ;  the  most  convenient,  an  argand  gas-burner.  I  have  of 
late  used  the  electric  light  very  satisfactorily. 


Fig.  11. 


Laryngoscopic  examination,  as  made  with  the  means  ordinarily  employed. 

To  examine  the  larynx  by  artificial  light,  we  should  proceed 
thus.  The  patient,  sitting  in  an  upright  position,  with  his  head 
inclined  slightly  backward,  is  placed  near  a  lamp,  burning  w^ith  a 
steady,  brilliant  light,  and  the  flame  of  which  is  behind  and  about 
on  a  level  wdth  his  eyes.  He  is  directed  to  open  his  mouth  w^idely, 
to  put  out  his  tongue,  and  to  hold  between  two  fingers  its  point 
enveloped  in  a  soft  napkin  or  handkerchief.  If  he  cannot  accom- 
plish this  readily,  the  observer  must  hold  the  protruded  tongue, 
or  a  tongue-depressor  must  be  employed.  The  observer  now  seats 
himself  directly  in  front  of  the  patient,  and  nearly  a  foot  from 


234 


MEDICAL   DIAGNOSIS. 


the  mouth.  Putting  on  his  spectacles  or  frontal  band,  he  throws 
a  disk  of  light  into  the  back  part  of  the  mouth  ;  he  then  rapidly 
introduces  the  laryngeal  mirror,  previously  heated  in  warm  water 
or  over  a  lamp  and  its  ])roper  temperature  ascertained  by  touching 
his  own  hand  or  eheek.  The  mirror,  great  care  being  taken  not 
to  bring  it  in  contact  with  the  tongue,  is  placed  with  its  back 
against  the  uvula,  w  hicli,  with  the  soft  palate,  is  pressed  backward 
and  upward  ;  the  lower  surface  of  the  laryngoscope  should  be 
firmly  applied  to^  or,  if  this  be  found  to  occasion  too  much  irrita- 
tion, should  be  held  near,  the  posterior  wall  of  the  pharynx.  The 
inclination  of  the  mirror  varies  with  the  position  of  the  patient  and 
the  parts  we  wish  the  more  particularly  to  explore.  As  a  general 
rule,  it  may  rest  at  an  angle  of  about  45°. 

When  the  mirror  is  stationary,  as  for  instance  in  the  Tobold 
laryngoscopic  lamp, — a  less  portable  but  far  easier  mode  of  illu- 
minating,— the  reflector  is  attached  to  the  lamp  by  a  freely  mova- 
ble brass  rod,  and  the  light  is  thus  thrown  into  the  mouth,  leaving 
the  examiner  unembarrassed.  When  the  mirror  has  been  intro- 
duced in  the  manner  described,  the  laryngeal  image  is  readily 
perceived.  We  see  the  epiglottis,  the  glottis,  the  cartilages,  the 
true  vocal  cords,  the  superior  thyro-arytenoid  ligaments  or  false 
vocal  cords,  and  in  some  cases  even  the  rings  of  the  trachea.  We 
may  be  able  to  discern  each  portion  of  the  laryngeal  aperture  with 
distinctness,  or  it  may  take  several  examinations  to  do  so. 

In   health,  the  color  of  the  various  parts  is  very  different. 

Stoerck  has  well  described  it  in 
likening  that  of  the  epiglottis, 
the  interior  of  the  larynx  below 
the  o-lottis,  and  of  the  cricoid 
cartilage,  to  the  coloration  of  the 
conjunctiva  of  the  eyelid ;  and 
the  hue  of  the  aryepiglottidean 
folds  and  the  prominences  of  the 
arytenoid  cartilages  to  that  of 
the  sums.  The  mucous  mem- 
brane  of  the  trachea  between  the 
rings  is  of  a  pale  pink  color ; 
the  vocal  cords  have  a  white,  glistening  look.  INIackenzie  takes 
special  notice  of  the  whole  of  the  under  surface  of  the  epiglottis 


Fig.  12. 


Laryngeal  image,  n^5  uBen  in  the  laryngoscope 
under  favorable  circumstances. 


DISEASES   OF   THE   UPPER   AIR-PASSAGES.  235 

being  in  some  cases  of  a  bright-red  hue ;  and  Gibb  points  out 
that  in  negroes  the  cartilages  of  Wrisberg  have  a  yellowish  tinge. 

The  laryngeal  image  in  the  mirror  bears  this  relation  to  the 
real  position  of  the  parts  :  the  right  vocal  cord  of  the  person  who 
is  examined  is  seen  on  the  left  side  of  the  mirror,  and  the  left 
vocal  cord  on  the  right ;  or,  to  state  the  matter  in  a  form  easily  to 
be  remembered,  the  cord  which  corresponds  to  the  right  hand  of 
the  patient  is  the  right,  that  seen  toward  his  left  hand  is  the  left. 
The  epiglottis  appears  in  the  laryngoscope  at  the  upper  portion 
and  behind ;  so  do  the  other  structures  which  lie  in  front.  The 
arytenoid  cartilages  appear  at  its  lower  portion,  and  toward  the 
front. 

To  judge  of  the  movements  of  the  vocal  cords,  we  tell  the 
patient  alternately  to  inspire  deeply  and  to  sound,  as  a  high  note, 
a  sound  like  "  ah."  During  this  the  vocal  cords  are  closely 
approximated  and  stretched,  and  the  epiglottis,  in  fact  the  whole 
larynx,  is  somewhat  elevated ;  while  during  a  full  inspiration  the 
cords  are  far  apart,  and  hence  the  glottis  is  wide  open.  To  obtain 
a  satisfactory  sight  of  the  deeper-seated  parts,  we  must  bear  in 
mind  that  the  more  the  surface  of  the  mirror  is  placed  horizon- 
tally, the  more  distinctly  they  come  into  view.  For  the  explora- 
tion of  these  structures,  and  particularly  of  the  trachea,  the  light 
must  be  thrown  from  below  upward  upon  the  laryngoscope.  To 
elevate  the  larynx  decidedly,  and  especially  to  bring  the  epiglottis 
fully  into  view,  the  patient  should  in  a  high  pitch  pronounce  ee 
as  in  the  word  see. 

In  some,  laryngoscopy  is  easy ;  a  conclusive  examination  may 
be  made  at  the  first  attempt.  In  others,  a  course  of  training  is 
required  to  subdue  the  sensibility  of  the  fauces,  which  may  be 
general,  or  be  limited  to  a  very  small  spot.  As  a  means  of  over- 
coming the  diiliculty,  sucking  small  pieces  of  ice,  or  the  previous 
administration  of  bromide  of  potassium,  or  the  local  use  of  a 
solution  of  cocaine  from  two  to  five  per  cent.,  is  useful.  But  the 
best  means  is  skill  in  the  use  of  the  instrument, — its  rapid  and 
decisive  handling. 

In  some  persons  with  very  irritable  throats,  I  have  obtained 
good  views  by  pressing  the  instrument  against  the  roof  of  the 
mouth,  instead  of  passing  it  back  into  the  pharynx,  and  by  alter- 
ing the  position  of  the  head  a  little,  tilting  it  more  backward. 


236  MEDICAL    DIAGNOSIS. 

The  epiglottis,  and  the  structures  at  the  entrance  of  the  windpipe, 
are  thus  readily  enough  brought  into  view  :  with  the  deeper  parts 
Ave  do  not  succeed  so  mcII  ;  but  in  many  cases  we  get  sufficient 
guide  for  topical  applications.  There  are  further  obstacles,  such 
as  a  rising  up  of  the  tongue,  greatly-enlarged  tonsils,  a  long  uvula, 
a  pendent  epiglottis,  all  of  which  at  times  interfere  with  our  inves- 
tigations. But  in  any  case  we  should  not  endeavor  to  make  the 
view  more  satisfactory  by  constantly  altering  the  position  of  the 
mirror.  It  is  better  to  introduce  it  repeatedly,  than  to  shift  it 
often  when  introduced,  or  to  keep  it  for  any  length  of  time  in 
the  patient's  mouth. 

To  acquire  quickness  of  manipulation,  one  of  the  best  means 
is  autolaryngoscopy.  We  may  readily  inspect  our  own  larynx  by 
the  method  recommended  by  George  Johnson,*  of  emjjloying  a 
toilet -glass  and  throwing  the  light,  with  the  reflector  worn  in  the 
ordinary  manner,  on  the  image  of  the  fauces  as  seen  in  the  toilet- 
glass  ;  the  laryngeal  mirror  is  then  introduced  into  the  mouth. 

If  the  mirror  be  passed  behind  the  uvula,  and  the  reflecting 
surface  directed  upward,  the  posterior  nares  may  be  examined. 
To  practise  rhinoscopy,  however,  the  mirror  should  be  small  and 
fixed  to  the  shaft  at  a  right  angle.  The  patient  is  directed  to  keep 
his  head  erect,  or  bend  it  slightly  forward,  and  while  his  mouth 
is  widely  open  a  strong  light  is  thrown  to  the  back  of  the  throat. 
But  before  the  rhinal  mirror  is  placed  in  position,  a  tongue- 
depressor  is  applied,  with  which  the  back  of  the  tongue  is  well 
pressed  down,  and  which  may  be  given  to  the  patient  to  hold. 
Yet  a  difficulty  remains, — namely,  to  get  the  uvula  out  of  the 
way.  This  is  not  easily  accomplished  without  a  palate-hook,  by 
which  means  the  uvula,  with  a  portion  of  the  soft  palate,  is 
gently  drawn  forward  and  upward,  the  handle  of  the  hook  being 
held  to  one  side  of  the  mouth  :  Voltolini's  palate-hook  widens  the 
pharyngo-nasal  space  satisfactorily,  or  Sajous's  soft-palate-elevator 
may  be  employed.  The  mirror,  with  its  reflecting  surface  up- 
ward, is  now  passed  along  the  tongue-depressor,  until  it  reaches 
the  posterior  wall  of  the  pharynx.  By  then  raising  somewhat  the 
handle  of  the  mirror,  we  obtain  a  view  of  the  septum ;  and  by 
slanting  the  mirror  first  toward  one  side  and  then  toward  the 

*  Lectures  on  the  Laryngoscope. 


DISEASES    OF   THE    UPPER    AIR-PASSAGES.  237 

other,  the  posterior  nares  and  the  orifices  of  tlie  Eustachian  tulDes 
may  be  inspected.  Electric  illumination  by  means  of  an  instru- 
ment attached  to  an  accumulator  has  been  employed  with  great 
adv^antage.* 

The  art  of  rhinoscopy  is  more  difficult  than  that  of  laryn- 
goscopy, and,  though  the  rhinal  mirror  aids  us  in  detecting  mor- 
bid appearances  which  would  otherwise  escape  observ^ation,  it  does 
so  neither  as  readily  nor  as  completely  as  the  laryngoscope.  By 
the  aid  of  this  we  can  discern  inflammation  of  various  parts  of 
the  larynx  ;  oedema  ;  ulcers  ;  cicatrices  ;  excrescences  and  morbid 
growths ;  irregularities  in  the  shape  of  the  glottis  and  in  the 
mobility  of  the  cords ;  palsies  of  individual  muscles ;  abscesses ; 
diseases  of  the  cartilages ;  and  other  abnormal  conditions  which, 
without  it,  could  not  be  recognized,  or,  to  say  the  least,  could  not 
be  discriminated  with  any  degree  of  certainty.  Indeed,  any  one 
who  attempts  a  positive  diagnosis  of  laryngeal  diseases  without 
the  laryngoscope  attempts  to  do  without  the  only  means  which 
renders  the  diagnosis  at  all  trustworthy,  and  is  guilty  of  neglect. 

Let  us  now  look  at  the  chief  diseases  of  the  larynx.  Grouped 
in  accordance  with  their  main  features,  and  without  classifying 
them  in  strict  obedience  to  laryngoscopic  inquiries,  they  may  be 
arranged  as  follows : 

Acute  Organic  Diseases. 

Inflammation  of  the  mucous  membrane  of  the  larynx — Acute  laryngitis. 

CEdema  of  the  glottis. 

Acute  affections  of  the  larvnx-\  a  n-  n  i  ,  ^  .. 

bpasmodic  and  pseudomembranous  laryngitis 
and  trachea  as  met  with  y         -m  i  j  ,  '    " 

1      — -b  alse  and  true  croup, 
in  children.  J 

Chronic  Organic  Diseases. 
Inflammation  of  the  mucous  membrane  of  a  part,  or  of  the  whole — Chronic 

laryngitis  in  its  various  forms. 
Destruction  of  the  cartilages. 
Growths  and  tumors  of  various  kinds. 
Ulcers,  simple  and  specific. 

Affections  of  the  Nerves. 
Spasm-  of  the  glottis.     (Laryngismus  stridulus.) 

Tvj  -u     ■     f  Functional,  or  purely  nervous  aphonia. 

JNervous  aphonia.  <  ■       r       j  f 

t-  Paralysis  of  the  muscles  of  the  A'ocal  cord. 
*  Felix  Simon,  Lancet,  March  21,  1885. 


238  MEDICAL   DIAGNOSIS. 

Acute  Laryngeal  Affections. 

Acute  Laryngitis. — In  its  mild  form,  acute  laryngitis  is 
neither  an  uncommon  nor  a  dangerous  disease.  In  its  severer 
form  it  is  much  more  uncommon,  and  very  much  more  dangerous. 
AVhen  it  is  slight,  it  occasions  simply  hoarseness ;  a  feeling  of 
tickling  and  irritation  in  or  near  the  larynx ;  a  trifling,  though 
annoying,  cough,  or  rather  a  constant  disposition  to  clear  the 
throat,  more  than  a  cough  ;  and,  owing  in  a  great  measure  to  a 
coexisting  inflammation  of  the  fauces,  some  difficulty  in  swallow- 
ing.    The  disorder  passes  off  in  the  course  of  a  few  days. 

When  the  inflammation  is  violent,  and  especially  when  it  in- 
volves the  submucous  tissues,  the  symptoms  are  much  aggravated, 
and  life  is  in  peril.  The  respiration  becomes  seriously  impeded ; 
with  each  breath  a  wheezino;  or  whistlino;  noise  is  heard.  There 
is  but  little  expectoration  ;  and  the  cough  is  distressing  and  pain- 
ful, and  has  a  harsh  sound.  The  voice  is  hoarse,  or  sinks  into 
a  scarcely  audible  whisper.  The  patient  knows  the  seat  of  his 
disease :  he  feels  that  it  lies  in  the  Avindpipe,  and  complains  of 
this  being  tender  when  pressed,  and  of  a  feeling  of  constriction 
in  the  throat.  There  is  difficulty  in  swallowing,  and  fever,  with 
a  full  pulse  and  flushed  face.  If  the  case  advance  unchecked, 
the  countenance  becomes  distressed  and  pale,  the  lips  bluish,  the 
pulse  irregular,  and  death  sets  in  with  all  the  signs  of  deficient 
aeration  of  the  blood  and  of  strangulation. 

The  disease  in  its  graver  form  runs  a  very  rapid  course.  If  in 
a  few  days  after  its  commencement  no  improvement  show  itself, 
life  does  not  last  long.  Sometimes  death  takes  place  on  the  first 
day  of  the  attack.  It  rarely  waits  for  the  sixth.  CEdema  of 
the  glottis  is  often  the  consequence  of  the  inflammation  and  the 
cause  of  the  danger. 

Acute  idiopathic  laryngitis  is  seldom  met  with  in  children. 
Occasionally  we  do  see  acute  laryngitis  in  them,  and  exhibiting 
the  same  features  as  in  the  adult ;  but  then  it  has  almost  always 
arisen  as  the  consequence  of  swallowing  irritating  substances,  and 
not  as  the  result  of  exposure  to  cold  or  wet. 

The  marked  symptoms  of  the  perilous  complaint  prevent  it 
from  being  overlooked,  and  render  its  discrimination  easy.  There 
is  fever  with  dyspnoea  in  the  acute  indmonary  affections  ;  Init  the 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  239 

voice  remains  unaltered,  and  they  exhibit  physical  signs  which 
acute  laryngitis  does  not, — they  show  rales,  or  abnormal  respira- 
tion-sounds; while  in  laryngitis  the  murmur  of  the  lungs  is  that 
of  health,  although  it  is  sometimes  enfeebled  by  the  impediment  in 
breathing,  or  obscured  by  the  shrill  sound  which  issues  from  the 
larynx.  We  find  difficulty  in  swallowing  and  some  hinderance  in 
breathing  in  tonsillitis ;  but  inspection  of  the  oral  cavity  imme- 
diately detects  the  source  of  the  disorder.  There  is  difficulty  in 
swallowing  in  jiharyngitis,  but  there  is  not  embarrassed  breathing, 
or  a  peculiar  voice,  or  cough,  and  the  fauces  appear  dusky  and 
injected,  \vhile  they  are  but  slightly  affected  in  laryngitis,  unless 
the  inflammation  of  the  larynx  have  supervened  upon  that  of  the 
throat.  Croup  resembles  acute  idiopathic  laryngitis  most  nearly  ; 
but  it  is  as  rare  in  the  adult  as  acute  laryngitis  is  in  the  child, 
and,  as  we  shall  presently  see,  obvious  differences  in  the  symp- 
toms exist. 

There  is  a  peculiar  form  of  inflammation  of  the  larynx,  diffuse 
cellular  laryngitis,  a  diffuse  inflammation  of  the  cellular  tissue, 
with  lymph  or  pus  infiltrated  in  the  submucous  tissue,  to  which 
attention  has  been  called  by  Henry  Gray.*  It  is  a  formidable 
affection,  which  bears  a  strong  likeness  to  erysipelatous  laryngitis, 
but,  what  is  not  by  any  means  constantly  the  case  in  this  disorder, 
the  symptoms  begin  in  the  fauces  and  larynx  ;  and,  wholly  unlike 
erysipelatous  laryngitis,  the  submucous  tissue  is  primarily  attacked, 
and  the  neck  becomes  greatly  swollen  from  the  effused  products 
around  the  larynx,  trachea,  and  oesophagus  filling  its  cellular 
tissue.  The  disease  begins  with  chills,  soreness  of  throat,  and  fever, 
soon  succeeded  by  a  hacking  cough,  by  dyspnoea,  by  a  dusky  hue 
of  the  fauces,  by  enlargement  of  the  tonsils  and  of  the  glands  in 
the  neighborhood  of  the  jaw,  and  by  great  difficulty  in  swallowing. 
As  the  complaint  proceeds,  the  neck  increases  greatly  in  size,  the 
fever  assumes  a  low  type,  and  the  patient  either  sinks  gradually 
or  dies  as])hyxiated,  perishing  sometimes  rapidly  from  a  speedy 
increase  of  the  laryngeal  oedema. 

Other  forms  of  inflammation  of  the  larynx  to  which  attention 
has  of  late  years  been  called  are  hemorrhagic  laryngitis,  an  acute 
catarrh  of  the  larynx,  attended  by  bleeding  from  the  inflamed 

*  Holmes's  System  of  Surgery,  vol.  iv. 


240  MEDICAL    DIAGNOSIS. 

membrane,  and  hiningcal  rheumatism.  This  generally  happens 
in  persons  of  rheunuitic  diathesis,  is  attended  with  considerable 
pain,  and  may  or  may  not  be  associated  with  other  signs  of  rheu- 
matism.* 

CEdema  of  the  Glottis. — The  danger  of  acute  laryngitis  of 
any  kind  is  much  aggravated  by  the  precise  seat  of  the  disease. 
When  the  inflammation  takes  place  immediately  around  the  glottis, 
and  causes  a  serous  fluid  to  transude,  crdemalous  faryngitis,  the  peril 
is  greatly  increased.  The  inspiration  is  audible,  noisy,  hissing,  and 
labored ;  there  is  a  distressing  sensation  of  constriction  or  obstruc- 
tion in  the  windpipe,  and  the  patient  makes  repeated  efforts,  by 
swallowing  or  by  hawking,  to  clear  his  throat  of  the  substance 
which  seems  to  be  clogging  it.  His  difficulty  of  breathing  is  in- 
tense, and  occurs  in  frightful  paroxysms,  sometimes  of  a  quarter  of 
an  hour's  duration,  during  the  whole  of  which  time  strangulation 
appears  to  be  imminent ;  and  often  he  does  perish  by  strangulation. 

This  grave  form  of  oedema  of  the  glottis  sometimes  follows  an 
extension  of  the  peculiar  inflammation  of  the  throat  in  the  ex- 
anthemata, or  is  of  erysipelatous  origin,  and  it  occasions  death 
quickly,  and  amidst  great  suffering.  But  the  axlcma  may  arise 
Avithout  preceding  acute  inflammation,  whether  this  be  specific  or 
not.  It  may  result  from  long-continued  pressure  on  the  trachea 
or  lar\'nx,  or  in  exceptional  instances  occur  in  connection  with 
Bright's  disease.  Again,  an  effusion  of  serum  may  cause  death 
suddenly  in  a  person  who  has  been  laboring  under  a  chronic 
laryngeal  disorder.f  Such  cases  of  oedema  of  the  glottis  are  dis- 
tinguished from  those  produced  by  active  laryngeal  inflammation 
by  the  absence  of  fever,  of  local  tenderness,  and  of  marked  difli- 
culty  of  deglutition.  It  is  true  that,  if  the  oedematous  affection 
ensue  upon  a  chronic  inflammation  of  the  larynx,  tenderness  and 
an  impediment  in  swallowing  may  be  observed.  But  the  history 
of  the  malady  and  the  non-existence  of  fever  leave  little  room  for 
error. 

The  diagnostic  sign  proposed  for  oedema  of  the  glottis — the 
swelling  of  the  epiglottis,  as  ascertained  by  the  touch — cannot  be 

*  Archambault,  These  de  Paris,  1886. 

t  As  in  tubercular  laryngitis,  Avhich  may  be  complicated  both"  with  acute 
and,  more  frequently,  with  chronic  oedema.  See  an  interesting  paper  on  the 
connection  in  Archives  de  Physiologic,  No.  G,  1882. 


DISEASES   OF   THE   UPPER   AIR-PASSAGES.  241 

relied  upon,  because  this  swelling  does  not  always  exist  to  an 
obvious  degree,  and,  even  when  it  does  exist,  is  not  readily  deter- 
mined by  the  finger.  In  the  acute  cases  of  OBdematous  laryngitis 
the  laryngoscope  shows  a  bright-red  mucous  membrane ;  some- 
times the  tiunid  epiglottis  presents  the  appearance  of  two  round 
red  swellings.  It  is  generally  erect  and  tense.  The  oedema  may 
be  altogether  below  the  glottis. 

Croup. — Croup  is  inflammation  of  the  larynx  and  trachea ;  but 
it  is  something  more.  It  is  a  spasmodic  action  of  the  muscles  of 
the  larynx,  which  spasmodic  action  gives  rise  to  much  of  the 
peculiar  cough,  the  stridor,  and  the  paroxysms  of  dyspnoea,  so 
characteristic  of  the  disease.  As  croup  is  thus  an  affection  com- 
posed, as  it  were,  of  several  distinct  elements,  it  differs  somewhat 
according  as  one  or  the  other  of  these  elements  preponderates. 
Thus,  the  inflammation  may  be  comparatively  slight,  yet  the 
spasm  play  a  very  prominent  part ;  or  the  inflammation  may  be 
very  severe,  and  result  in  the  formation  of  a  false  membrane. 
To  the  first  class  belongs  the  disorder  known  as  false  croup, 
catarrhal  croup,  spasmodic  laryngitis ;  to  the  second,  the  true  or 
membranous  croup. 

False  or  catarrhal  croup. — This  is  one  of  the  common  diseases 
of  childhood.  Its  seizures  happen  chiefly  at  night;  and  the  child 
that  has  gone  to  bed  well,  or  perhaps  fretful  from  teething,  or 
with  a  slight  catarrh,  wakes  up  suddenly  in  a  state  of  alarm, 
breathing  with  difficulty.  It  coughs  with  violence  and  at  short 
intervals,  and  the  cough  is  noticed  to  be  loud  and  ringing  and 
hoarse;  and  so  are  the  voice  and  the  cry.  Each  inspiration  is 
attended  with  that  shrill,  "  croupy"  sound  which,  once  heai;d,  is 
never  forgotten.  The  face  is  flushed,  the  pulse  frequent,  and  the 
temperature  but  little  above  the  normal.  The  paroxysm  continues 
in  this  manner  for  about  an  hour ;  the  breathing  then  becomes 
quiet,  the  child  falls  asleep,  and  rests  well  until  toward  morning, 
when  the  attack  is  apt  to  be  renewed.  The  little  patient  may, 
however,  escape  this  altogether,  and  keep  well ;  or  else  the  parox- 
ysm recurs  the  next  night,  or  for  several  nights  in  succession.  In 
the  intervals  the  voice  and  respiration  are  natural,  there  is  little 
or  no  fever,  little  or  no  cough.  Yet  sometimes  a  cough  remams, 
which  has  every  now  and  then  a  croupal  sound ;  the  voice,  too,  is 
slightly  hoarse,  but  not  smothered  or  extinct,  as  in  true  croup. 

16 


242  MEDICAL   DIAGNOSIS. 

False  croup  most  frequently  follows  exposui-c.  It  is  very 
rarely  fatal.  The  few  eases  whieli  have  been  examined  presented 
signs  of  inflammation  in  the  larynx  and  traciiea,  inadequate 
m  themselves  to  account  for  death.  Yet  such  inflannnation 
probably  always  exists  to  a  greater  or  less  degree.  Cases  in 
which  it  is  extensive  and  severe,  without  having  led  to  a  plastic 
exudation,  approach  in  their  persistency  and  in  the  character  of 
their  symptoms  closely  to  true  croup.  Indeed,  one  form  of 
the  complaint  may  run  into  the  other,  which  is  not  astonishing, 
since  they  are  not  two  diseases,  but  only  two  forms  of  the  same 
disease. 

The  main  element  in  the  production  of  the  synqitoms  of  false 
croup  is  undoubtedly  spas^n  of  the  glottis.  But  (aryiif/ismm  strid- 
idus,  as  spasm  of  the  glottis  is  called  by  many,  while  it  may 
complicate  any  affection  of  the  larynx  and  trachea,  may  also  exist 
independently,  from  central  or  direct  or  reflex  causes  of  irritation. 
The  laryngeal  spasm  may,  therefore,  form  a  distinct  disorder, 
which  differs  from  false  croup  by  the  absence  of  all  inflammation 
and  by  several  circumstances  which  proclaim  its  non-identity,  such 
as  its  usual  association  with  rickets,  its  occurrence  in  adults  as  well 
as  in  children,  and  its  frequent  association  with  other  convulsiv^e 
symptoms, — with  distortion  of  the  face,  spasmodic  contraction  of 
the  hands  and  feet,  and  general  convulsions. 

As  in  croup,  the  seiziu-es  are  apt  to  take  place  at  night.  Gen- 
erally the  child  has  been  fretful  from  teething,  or  from  gastric  or 
intestinal  irritation,  when  suddenly  an  attack  of  difficult  breathing 
occurs,  accompanied  by  several  loud,  crowing  inspirations,  and 
by  an  appearance  of  the  most  manifest  distress  and  of  tln-eaten- 
ing  suffocation ;  yet  the  paroxysm  is  not  associated  eitlier  with 
cough,  or  with  fever,  or  with  an  altered  voice  or  a  materially 
changed  cry.  A  fit  of  this  kind  may  be  repeated  twenty  or  thirty 
times  a  day.  It  may  terminate  fatally  in  a  short  time ;  usually, 
however,  the  paroxysms  are  spread  over  weeks,  or  even  over  a 
longer  period.  Thus,  in  addition  to  the  frequent  combination 
with  other  convulsive  symptoms,  the  protracted  duration  of  the 
disease,  and  the  absence  of  febrile  disturbance,  of  hoarseness,  and 
of  cough,  point  out  the  distinction  between  laryngeal  spasm  and 
spasmodic  laryngitis.  In  laryngismus  stridulus,  too,  as  Squire 
has  told  us,  Ioav  temperature  will  exclude  the  complication  of 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  243 

laryngitis.*  Laryngeal  spasm  also  occurs  in  the  laryngeal  crises 
of  tabes;  the  absent  knee-jerk  and  the  ataxia  tell  us  its  meaning. 

True  or  membranous  croup. — True  croup  is  a  formidable  aifec- 
tion,  in  which  there  is  inflammation  that  results  in  the  formation 
of  a  false  membrane.  The  plastic  exudation  is  found  lining  the 
larynx,  extending  into  the  trachea  or  down  into  the  bronchial 
tubes,  and  is  seen  in  the  fauces  and  on  the  tonsils. 

The  symptoms  of  this  dangerous  malady  are :  the  same  brazen 
cough,  the  same  stridulous  breathing,  as  in  false  croup ;  a  de- 
cided change  in  the  voice,  dyspnoea,  and  fever.  But  all  these 
symptoms  do  not  show  themselves  at  once.  The  disease  usually 
begins  with,  or  rather  is  preceded  by,  slight  fever  and  catarrh, 
and  some  hoarseness.  This  may  last  for  a  few  days,  when  the 
symptoms  peculiar  to  croup  manifest  themselves.  The  cough 
attracts  attention  by  its  ringing  sound,  and  at  the  same  time,  or 
shortly  after,  the  characteristic  croupal  respiration  is  perceived. 
High  fever  and  difficulty  in  breathing  soon  set  in,  and,  although 
they  exacerbate  and  remit,  only  cease  when  the  disease  ceases. 
There  is  much  thirst,  no  appetite ;  but  what  is  taken  is  readily 
enough  swallowed.  The  voice  is  changed  almost  from  the  onset. 
It  is  hoarse  and  whispering,  and,  as  the  disease  advances,  often 
becomes  totally  suppressed. 

The  child  remains  in  this  condition  for  several  days  :  restless, 
with  its  head  thrown  back,  its  respiration  labored,  and  the  croupal 
sound  never  completely  disappearing.  Sometimes,  but  far  from 
always,  solid  masses  of  membrane  are  coughed  up.  Finally,  the 
cough  stops  altogether ;  the  intervals  between  the  parox}-sms  of 
dyspnoea  are  effaced  ;  the  countenance  becomes  livid ;  the  skin  loses 
its  sensibility ;  the  extremities  grow  cold ;  and,  unless  relief  be 
afforded,  either  by  medicinal  means  or  by  an  operation,  the  little 
sufferer  dies  comatose  or  suffocated.  The  fatal  termination  is  not 
unfrequently  hastened  by  an  intervening  attack  of  bronchitis  or 
of  pneumonia, — a  fact  which  teaches  us  not  to  neglect  examining 
the  lungs  in  cases  of  croup,  so  as  to  be  sure  that  no  disease  is 
there  silently  running  its  course  with  its  symptoms  masked  by 
the  tracheal  malady. 

The  application  of  a  stethoscope  to  the  larynx  or  trachea  does 

*  Transactions  of  the  Obstetrical  Society  of  London,  vol.  xii. 


244  MEDICAL    DIAGNOSIS. 

not,  give  ns  much  information  as  to  the  exact  seat  and  the  extent 
of  the  affection  of  the  windpipe.  Still  it  is  not  without  value.  It 
may  enable  us  to  judge  of  the  position  of  the  exudation,  for  we 
may  occasionally  hear  a  vibrating  sound,  as  if  a  membrane  were 
being  tossed  to  and  fro  by  a  current  of  air.  In  a  case  that  came 
under  my  notice  some  years  ago,  this  sign  was  perceived  with  great 
distinctness  at  the  lower  part  of  the  trachea  and  toward  the  com- 
mencement of  the  left  bronchial  tube ;  and  at  the  autopsy,  at  exactly 
this  point  Mas  found  a  thick  layer  of  membrane  lying  unattached 
in  the  tube.  Laryngoscopic  examinations  in  croup  are  difficult 
of  accomplishment ;  but,  Avhen  successful,  they  often  show  innno- 
bilitv  of  the  vocal  cords,  and  the  arvtcnoid  cartilaircs  held  together 
by  false  membrane  in  the  interarytenoid  space.* 

Croup  is  a  disease  not  apt  to  be  mistaken.  Yet  we  must  be 
cautious  not  to  attach  too  much  weight  to  any  one  of  the  symp- 
toms ;  we  ought  rather  to  judge  of  the  existence  of  the  disorder 
by  their  grouping.  Thus,  the  ringing  cough  is  in  itself  by  no 
means  diagnostic,  for  it  may  occur  in  some  chronic  laryngeal 
affections,  and  it  is  met  with  in  children  suffering  from  intestinal 
irritation.  The  stridulous  respiration  is  also  heard,  or  at  all  events 
there  is  a  tolerably  close  copy  of  it,  in  simple  spasm  of  the  glottis, 
and  sometimes  when  foreign  bodies  have  found  their  way  into  the 
larynx.  The  paroxysms  of  apjiarent  suffocation  happen  equally 
in  oedema  of  the  glottis.  Not  even  the  symptom  considered  of 
all  the  most  pathognomonic — the  expectoration  of  false  membrane 
— is  strictly  so,  since  this  may  come  from  the  bronchial  tubes  or 
from  the  throat.  But  when  we  take  the  symptoms  collectively, 
— the  ringing  cough,  the  peculiar  respiration,  the  dyspnoea  ag- 
gravated in  paroxysms,  the  changed  voice,  the  fever,  the  expec- 
toration ;  when  we  regard  the  comparatively  short  duration  of 
the  disease, — there  is  but  one  interpretation  of  the  phenomena 
possible,  and  that  is  true  croup. 

It  is,  of  course,  of  the  utmost  consequence  to  distinguish  be- 
tween spasmodic  laiyngitis  or  fahe  croiip  and  membranous  croup. 
The  main  difference  consists  in  this  :  in  the  former,  the  invasion 
is  usually  more  sudden ;  we  do  not  find  the  pharyngeal  exudation 
so  often  seen  in  true  croup ;  there  is  little  fever,  or  this  disappears 

*  Pieniazek,  Arch.  f.  Kinderk.,  x.  5. 


DISEASES    OF    THE    UPPER   AIR-PASSAGES.  245 

with  the  paroxysm ;  and  so  do  the  croupal  breathing,  and,  to  a 
great  extent,  the  hoarse  voice  and  the  loud,  harking  eougli.  The 
disorder  lasts  rarely  more  than  two  or  three  days,  the  attack  usually 
occurring  at  night ;  whereas  in  true  croup  the  duration  is  seldom 
less  than  from  four  to  six  days,  the  disease  progresses  steadily, 
and  the  voice  and  respiration  show  at  all  times  the  nature  of  the 
affection.  Then  in  the  latter  we  find  expectoration  of  false  mem- 
brane. This  is,  indeed,  the  most  absolute  proof;  yet  the  absence 
of  membrane  in  what  is  coughed  np  or  vomited  is  not  a  positive 
sign  that  the  case  is  not  one  of  membranous  croup.  The  mem- 
brane may  be  retained  in  the  larynx  ;  and  we  meet,  indeed,  with 
instances  in  which  it  is  impossible  to  say  whether  the  inflam- 
mation has  or  has  not  produced  a  plastic  exudation ;  whether,  in 
other  words,  the  case  is  a  severe  one  of  false  croup,  or  one  of 
membranous  croup. 

The  disorders  which,  next  to  false  croup,  are  most  likely  to 
be  mistaken  for  the  formidable  malady  under  consideration,  are : 
acute  laryngitis,  oedema  of  the  glottis,  diphtheria,  retropharyn- 
geal and  retrolaryngeal  abscesses. 

Acute  laryngitis  is,  like  croup,  a  disease  of  short  duration,  and, 
like  croup,  attended  with  a  changed  voice,  with  a  harsh  cough, 
and  with  dyspnoea.  But  it  attacks  adults,  not  children.  It  pre- 
sents difficulty  in  swallowing,  for  which  the  slight  marks  of  in- 
flammation in  the  fauces  are  insufficient  to  account ;  whereas  in 
croup,  in  spite  of  the  pharyngeal  exudation,  there  is  little  or  no 
difficulty  in  swallowing.  A  form  of  laryngitis,  however,  happens 
in  children,  Avhich  is  very  liable  to  be  considered  as  croup  :  it  is 
the  secondary  laryngitis  of  the  exanthemata,  especially  of  variola. 
Attention  to  the  history  of  the  case,  and  to  the  circumstance  of 
the  inflammation  having  spread  from  the  throat  downward,  will 
go  a  great  way  toward  forming  a  correct  opinion  of  the  disease. 
Yet  the  diagnosis  is  sometimes  one  of  extreme  difficulty,  and, 
if  the  characteristic  expectoration  of  croup  be  absent,  the  most 
accomplished  physician  may  be  deceived. 

GEdema  of  the  glottis  resembles  croup  in  the  dyspnoea,  the  fits 
of  suffocation  and  of  coughing,  the  altered  voice,  and  the  noisy 
inspiration.  It  resembles  it  further  in  the  fact  that  most  of  the 
symptoms  do  not  disappear  in  the  intervals  between  the  par- 
oxysms.    Here  is  certainly  a  strong  likeness.     But  the  cough 


246  MEDICAL    DIAGNOSIS. 

ha.'^  not  the  croiiixil,  brazen  sdiuuI  ;  exjiiration  is  eoniparatively 
inienibarVassed ;  there  is  no  fever,  unless  the  tedema  oeeur  in  the 
course  of  an  aeute  affection ;  and,  above  all,  a3dema  of  the  glottis 
is  a  disease  of  adults,  and  is  unattended  with  the  peculiar  expec- 
toration. Again,  the  history  of  the  case  often  guards  against  error, 
for  redenia  of  the  glottis  happens  frequentl}',  perhaps  most  fre- 
quently, in  those  who  have  been  long  laboring  under  ulcerative 
laryngitis.  In  cases  in  which  we  are  able  to  use  the  laryngeal 
mirror,  the  peculiar  oedematous  look  of  tlie  parts  is  readily 
recognized. 

The  sore  throat  of  diphtlieria  may  be  attended  by  the  same 
expectoration  as  crouj) ;  the  walls  of  the  pharynx,  and  the  fauces, 
too,  are  coated  with  false  membrane.  But  we  know  that  the  wind- 
pipe is  not  the  seat  of  the  complaint  by  the  absence  of  paroxysms 
of  cough  and  of  difficulty  in  breathing,  and  by  the  voice  being 
unchanged,  or  somewhat  nasal  but  not  husky  or  extinct.  Into  the 
relation  of  membranous  croup  to  laryngeal  diphtheria  we  shall 
farther  on  inquire.  We  shall  merely  here  record  our  opinion  that, 
while  the  majority  of  cases  of  so-called  membranous  croup  are 
really  laryngeal  diphtheria,  there  is  such  a  thing  as  membranous 
croup,  which  is  not  diphtheria. 

Retropharyngeal  abscesses  share  with  croup  the  dyspnoea,  the 
stridulous  respiration,  and  the  altered  voice.  They  do  not,  how- 
ever, share  with  it  the  expectoration  of  false  membrane  or  the 
peculiar  cough ;  and,  further,  in  croup  there  is  not  that  difficulty 
in  swallowing,  or  that  evident  tumefaction  and  stiffness  of  the 
neck,  nor  can  a  tumor  be  recognized  by  the  touch,  as  it  can  be 
when  an  abscess  is  seated  behind  the  walls  of  the  pharynx. 
Moreover,  the  dj-spnoea  and  the  voice  present  somewhat  different 
characteristics.  In  the  case  of  abscess,  the  former  is  greatly 
augmented  or  paroxysms  of  it  are  brought  on  by  attempts  at 
deglutition ;  it  is  always  preceded  by  dysphagia,  is  increased  by 
pressure  against  the  larynx,  and  is  frightfully  aggravated  by  the 
horizontal  position.  In  croup,  the  patient  seeks  relief  by  throw- 
ing his  head  back,  and  although  he  loses  his  voice  and  speaks  in 
a  hardly  audible  whisper,  still  the  words  are  sufficiently  distinct ; 
while  an  abscess  gives  a  nasal  or  guttural  tone  to  the  voice,  which 
makes  it  impossible  to  understand  what  is  being  said. 

Retrolaryngeal  abscesses  following  inflammation  of  the  areolar 


DISEA.SES   OF   THE   UPPER   AIR-PASSAGES.'  247 

tissue  of  the  retrolaiyngeal  space  present  dyspnoea,  attacks  of  suf- 
focation, and  cough  like  those  of  croup,  and  run,  moreover,  gen- 
erally an  acute  course  ;  but  they  also  present  dysphagia  and  severe 
pain,  occasioned  by  pressing  on  the  thyroid  cartilage.* 

Abscess  of  the  larynx  bears  a  strong  resemblance  to  retro- 
pharyngeal abscess,  and  may  be,  like  it,  mistaken  for  croup. 
Abscess  of  the  larynx  in  its  acute  and  primary  form  is  not  a 
frequent  disease :  rare  in  adults,  it  is  still  rarer,  as  Parry  points 
out,t  in  children.  No  swelling  can  be  detected  in  the  pharynx 
to  account  for  the  pain,  the  cough,  the  difficult  breathing  and 
impeded  swallowing ;  but  on  close  observation  it  is  found  that 
the  larynx  projects,  and  that  there  is  induration  at  the  posterior 
margin  of  the  thyroid  cartilage.  The  neck  is  not  markedly 
swollen,  as  in  diifuse  inflammation  of  the  cellular  tissue.  With 
the  laryngoscope  we  observe  a  circumscribed  swelling,  red  at  its 
base,  and  often  yellowish  at  its  apex.  We  do  not  find,  as  we  so 
commonly  observe  in  croup,  that  both  inspiration  and  expiration 
are  interfered  with  ;  the  latter,  indeed,  may  be  both  unembarrassed 
and  noiseless. 

Further,  croup  may  be  mistaken  for  tonsillitis,  for  capillary 
bronchitis,  for  hooping-cough,  or  for  the  presence  of  foreign  bodies 
in  the  larynx  or  trachea.  But  the  points  of  distinction  are  evi- 
dent. In  tonsillitis,  the  breathing  is  not  at  *all  or  but  very  slightly 
impaired ;  and  a  glance  into  the  mouth  is  sufficient  to  reveal  the 
real  nature  of  the  malady.  In  capillary  bronchitis,  there  is  dysp- 
noea, as  in  croup  ;  but  the  dyspnoea  is  unremitting,  and  associated 
with  fine  rales  in  the  lungs,  and  not  with  a  ringing  cough,  a  harsh 
tracheal  breathing,  a  hoarse  voice.  In  hooj)ing-cough,  paroxysms 
of  coughing  and  of  obstructed  respiration  occur ;  but  then  follows 
the  distinctive  hoop ;  and  there  is  no  fever,  the  voice  is  not  husky, 
and  the  child  does  not  suffer  between  the  spells.  Foreign  bodies 
in  the  loindpipe  give  rise  to  stridulous  breathing  and  to  cough,  but 
they  do  not  often  mimic  croup  closely  enough  to  deceive ;  and  the 
absence  of  the  peculiar  cough  and  of  fever,  and  the  history  of  the 
case,  prevent  error  ;  so  also  does  attention  to  the  fact  that  the  signs 
vary  as  the  foreign  body  shifts   its  position.     Furthermore,  as 


*  Goix,  Archives  Generales  de  Medecine,  Oct.  1882. 
f  Philadelphia  Medical  Times,  June,  1873. 


248  MEDICAL   DIAGNOSIS. 

Gross*  in  liis  elaborate  work  points  out,  the  embarrassed  breathing 
caused  by"  a  foreign  body  is  eliicfly  found  in  expiration. 

Chronic  Laryngeal  Affections, 

Of  the  chronic  diseases  of  the  larynx,  chronic  inflammation  of 
the  mucous  membrane,  and  the  clianges  produced  in  it  by  inflam- 
mation, tliickening  and  ulceration,  are  the  most  common. 

Chronic  Laryngitis. — ^Alteration  of  the  voice,  cough,  and  an 
uneasy  feeling  in  the  larynx  are  the  main  symptoms.  The  cough 
is  at  first  dry,  but  when  of  any  standing  is  followed  by  a  yellowish 
opaque  expectoration.  It  either  presents  nothing  peculiar  in  its 
tone  or  else  is  harsh  and  barking.  The  breathing  is  little,  if  at  all, 
embarrassed,  except  when  the  mucous  textures  are  greatly  thick- 
ened or  ulcerated.  In  that  case  there  is  dyspnoea,  the  respiration 
is  apt  to  be  noisy  and  the  voice  completely  lost,  because  the  vocal 
cords  have  also  sufiered.  There  is,  moreover,  consideral)le  pain 
on  pressure ;  the  sputum  is  muco-purulent,  or  else  purulent  and 
streaked  with  blood  ;  and  sometimes,  if  the  cartilages  also  be  in- 
volved, fragments  of  them  are  expectorated,  and  by  the  touch  we 
recognize  the  chano;ed  state  of  the  tube. 

The  symptoms  of  chronic  laryngitis  are  purely  local.  It  is 
only  when  there  is  considerable  ulceration  or  a  progressive  altera- 
tion of  structure  in  the  affected  part  that  the  general  health  gives 
way.  Yet  chronic  laryngitis  is  frequently  found  to  be  connected 
with  a  broken  constitution,  because  the  inflammation  of  the  larynx, 
both  in  its  simple  and  in  its  ulcerated  form,  is  often  combined 
with  a  tubercular  cachexia,  or  M'ith  syphilis.  In  every  patient, 
therefore,  suffering  from  chronic  laryngitis,  we  must  endeavor  to 
ascertain  whether  either  of  these  morbid  conditions  is  present. 
Chronic  laryngitis  frequently  turns  out,  on  thorough  examination, 
to  be  laryngitis  linked ,  to  a  serious  pulmonary  difficulty  ;  or  we 
detect  ulcers  in  the  jjharynx  associated  with  those  in  the  larynx 
and  cicatrices,  and  are  enabled  to  trace  clearly  the  ravages  of 
constitutional  syphilis. 

As  seen  with  the  laryngoscope  in  chronic  laryngitis,  hyperemia, 
general  or  partial,  is  present,  associated  in  cases  of  long  standing 
with  considerable  and  uniform  swelling  of  the  mucous  membrane  ; 

*  On  Foreign  Bodies  in  the  Air-Passages. 


DISEASES    OF   TPIE    UPPER    AIR-PASSAGES.  249 

the  vocal  cords  are  often  uneven  at  their  edges,  and  there  may  be, 
chiefly  between  the  arytenoid  cartilages,  superficial  ulcers. 

Chronic  laryngitis  is  liable  to  be  mistaken  for  an  aneurism  of 
the  aorta,  or,  more  strictly  speaking,  an  aneurism  of  the  aorta  is 
liable  to  be  regarded  and  treated  as  a  case  of  chronic  laryngitis. 
The  distinction,  as  will  hereafter  be  sliown,  is  mainly  made  by 
attention  to  the  physical  signs ;  often,  too,  the  paralysis  of  a  vocal 
cord  is  of  great  significance. 

Cases  of  functional  or  nervous  aphonia,  too,  are  sometimes  con- 
founded with  chronic  laryngitis ;  and  it  is  by  no  means  always 
easy  to  avoid  this  error.  The  loss  of  voice  may  be  either  partial 
or  complete.  It  not  unfrequently  comes  on  without  any  previous 
warning ;  and  this  fact  aids  us  greatly  in  diagnosis.  So  does  the 
absence  of  cough,  of  expectoration,  of  local  pain,  and  of  all  diffi- 
culty in  breathing ;  for  none  of  these  symptoms  are  commonly 
observed  in  aphonia  which  is  solely  nervous.  One  of  the  causes 
of  the  disorder  is  overstimulation  of  the  vocal  nerves,  by  straining 
the  voice  in  singing  or  in  speaking.  We  also  meet  with  it  as 
occasioned  by  narcotics  or  by  lead  poisoning,  and  perhaps  most 
frequently  as  a  reflex  manifestation,  due  to  irritation  of  the  intes- 
tines by  worms,  or  to  a  disorder  of  the  uterine  system.  In  these 
instances  of  nervous  aphonia  the  voice  suddenly  disappears  and 
as  suddenly  reappears,  a  phenomenon  not  unusual  in  the  aphonia 
of  hysteria ;  and  we  may  have  from  impaired  but  not  wholly  lost 
power  the  voice  absent  only  for  some  hours  daily.  It  is  evident 
that  in  all  cases  of  nervous  aphonia  the  laryngoscope  will  assist  us 
greatly,  as  it  will  show  the  true  condition  of  the  parts,  as  regards 
both  their  structure  and  their  mobility.  It  also  aids  us  in  dis- 
tinguishing these  laryngeal  disorders  from  cases  of  aphonia  due  to 
want  of  strength  in  breathing, — to  want  of  power  in  expiration. 

Enlarged  bronchial  and  cervical  glands,  and  an  aneurism  which 
paralyzes  the  vagus  and  the  recurrent  nerve,  also  produce  hoarse- 
ness, and  ultimately  complete  loss  of  voice.  Under  such  circum- 
stances, the  trachea  is  insensible  to  pressure  ;  there  is  a  short  cough, 
attended  often  with  loud  tracheal  rales  ;  and  we  observe  attacks  of 
dyspnoea,  with  a  noisy,  hissing  respiration.  The  practical  lesson 
which  all  such  cases  teach,  is  to  remember  that  the  symptom 
considered  most  characteristic  of  chronic  laryngeal  inflammation 
— the  altered  voice — may  occur  when  no  laryngitis  exists ;  also  to 


250  MEDICAL   DIAGNOSIS. 

examine  with  the  laryngoscope,  and  to  note  the  effect  of  palsy  of 
the  muscles  the  result  of  nerve-pressure. 

Now,  in  the  nervous  forms  of  aj)h()nia  just  alluded  to,  with 
the  exception  of  those  caused  by  pressure,  the  loss  of  voice  is  due 
to  deficient  power,  and  the  cords  move  sluggishly  or  not  at  all. 
AVhen  the  disorder  reaches  a  high  degree,  we  perceive,  on  looking 
into  the  laryngeal  mirror,  that  the  vocal  cords  do  not  approximate 
as  the  patient  attempts  to  say  a  or  o.  But,  besides  these  cases, 
owing  to  general  M'ant  of  force,  Ave  find  cases  of  sjxism  of  the  tensors 
of  the  vocal  cords  with  most  peculiar,  partially  interrupted  voice, 
and  of  absolute  j^a^'cflysis  of  individual  rmiscles,  as  of  one  adductor 
of  a  cord  ;  or  of  one  or  both  posterior  crico-arytenoids,  or  abductors ; 
or  of  the  crico-thyroids,  or  tensors.  In  some  of  these  there  is  con- 
siderable dyspnoea,  with  noisy  breathing ;  in  all  the  laryngoscope 
aifords  the  only  means  of  diagnosis.  In  paralysis  of  the  tensors 
of  the  vocal  cords,  the  crico-thyroicl  muscles,  there  is  inability  to 
use  with  any  freedom  the  higher  notes ;  the  voice  is  rough,  and 
viewed  with  the  mirror  we  find  in  phonation  a  want  of  longitudinal 
tension.  It  most  frequently  results  from  overstraining  the  voice, 
and  is  apt  to  be  bilateral.  Palsy  of  the  thyro-epiglottic  muscles 
has  its  connnon  origin  in  diphtheria.  The  epiglottis  stands  erect, 
and  does  not  move  during  attempts  at  deglutition.  In  palsy  of  the 
relaxors  of  the  vocal  cords,  the  thyro-arytenoid  muscles,  the  deep 
tones  are  nearly  gone.  It  is  often  unilateral,  and  comes  mostly 
from  overexertion  of  the  voice  during  catarrhal  laryngitis.  Viewed 
in  the  laryngeal  mirror,  the  edges  of  the  cords  do  not  approach  in 
the  median  line,  and  the  edges  seem  excavated.  In  paralysis  of 
the  posterior  crico-arytenoid  muscles,  we  see  in  the  mirror  the 
glottis  merely  as  a  narrow,  slit,  becoming  still  narrower  during 
inspiration.  There  is  no  disturbance  of  voice,  and  scarcely  any 
sign  of  lar}'ngeal  catarrh,  but  there  is  most  marked  and  noisy 
laryngeal  dyspnoea.  This  paralysis  of  the  abductors  may  happen 
from  compression  of  the  recurrent  nerves  by  an  organic  stricture 
of  the  oesophagus.*  We  also  encounter  sensory  neuroses  of  the 
larynx,  and  among  these  hypersesthesia  is  common. 

Chronic  laryngitis,  or  rather  its  chief  symptom,  loss  of  voice,  is 
at  times  feigned ;  and  the  deception  may  be  kept  up  for  an  indefi- 

*  Case  of  Dujardin,  Annales  des  Maladies  de  I'Oreille,  1887. 


DISEASES   OP   THE   UPPER   AIR-PASSAGES.  251 

nite  period.  Yet  we  possess,  in  the  use  of  an£Estlietics,  the  means 
of  detecting  the  fraud  at  any  moment.  Just  before  the  impostor 
falls  into  the  deep  sleep  produced  by  ether,  or  as  he  is  recovering 
from  the  insensibility  it  occasions,  his  will  no  longer  controls  his 
voice,  and  he  speaks  in  his  natural  tone,  or  even  screams  violently. 

No-w,  under  the  term  chronic  laryngitis,  which  formerly  for 
\\^ant  of  more  precise  knowledge  was  made  to  embrace  most  kinds 
of  chronic  diseases  of  the  larynx,  many  different  morbid  processes 
are  embraced,  the  exact  nature  and  seat  of  which  we  may  discrim- 
inate by  the  laryngoscope.  Thus,  the  disorder  may  be  wholly, 
or  nearly  wholly,  confined  to  the  epiglottis.  We  may  find  this 
structure  highly  congested  and  enlarged ;  we  may  be  able  to  note 
that  it  is  pendent,  almost  completely  covering  the  glottis ;  and  it 
is  frequently  the  seat  of  ulceration.  The  attending  symptoms 
in  any  case  are  those  regarded  as  characteristic  of  a  greater  or 
less  degree  of  laryngeal  inflammation.  In  instances  of  ulceration, 
there  is  soreness  with  pain  in  swallowing,  hoarseness  and  irritative 
cough,  followed  at  times  by  blood-streaked  expectoration.  The 
ulceration  may  terminate  in  total  destruction  of  the  epiglottis. 

When  the  vocal  cords  are  affected,  we  recognize  in  the  laryngeal 
mirror  either  their  reddening  in  part  or  entirely,  or  their  indura- 
tion and  thickening,  or  we  observe  oedematous  swelling  in  and 
around  them,  or  their  ulceration ;  and  we  can  usually  detect 
during  breathing  and  phonation  their  impaired  action.  The  in- 
flammatory redness  may  be  only  in  one  cord.  Small  collections 
of  mucus  are  often  found  adhering  to  different  parts  of  the  lar}Ti- 
geal  membrane.  Now,  all  these  conditions  are  generally  combined 
with  marked  aphonia ;  the  voice,  indeed,  may  be  reduced  to  the 
merest  whisper.  Venous  congestion  of  the  larynx  is  so  rare  an 
affection  that  Mackenzie  has  met  with  but  four  cases  of  it.*  In 
making  our  diagnosis  we  must  always  be  careful  to  find  out  if  the 
laryngeal  phenomena  be  not  secondary,  forming  part  of  a  general 
morbid  state,  such  as  dropsy,  tuberculosis,  syphilis,  or  changes  in 
the  blood.  Chronic  hypertrophy  of  the  ventricular  bands  is  the 
result  of  inflammatory  thickening,  and,  as  Tauberf  proves,  occurs 
mostly  in  those  who  use  the  voice  much  in  their  professional 
vocations. 

*  Diseases  of  the  Throat  and  Nose,  voh  i.,  1880.         f  Cincin.  Lancet,  1887. 


252  MEDICAL    DIAGNOSIS. 

Diseases  of  the  cartilages  and  of  the  jicnchondriiim  are  still 
more  frequently  oeeasioned  by  the  eDiiditions  alluded  to  :  tubereu- 
losis,  sy})liilis,  and  low  forms  of  fever  are,  at  all  events,  the  states 
^\•ith  wliic'h  they  are  eommonly  combined.  The  aifection  often 
begins  in  the  subnuieous  tissue,  and  the  ulceration  spreads  until 
the  cartilaginous  parts  of  the  larynx  are  involved.  The  arytenoid 
cartilages  are  generally  first  attacked ;  and  portions  of  these  car- 
tilages may  be  thrown  oif  and  expelled.  At  times  pus  is  formed 
which  gives  rise  to  swellings  that  can  be  recognized  by  the  aid  of 
the  laryngeal  mirror ;  sometimes  a  displacement  of  the  cartilages 
takes  place,  before  any  portion  of  them  is  completely  separated, 
and  the  most  distressing  and  dangerous  attacks  of  suifocation 
result ;  or  the  perichondritis  may  lead  to  the  development  of 
bone-substance  and  a  constriction  of  the  tube.  In  some  instances 
the  purulent  collection  presses  on  a  vocal  cord,  which,  when  the 
laryngoscope  is  used,  may,  as  Tuerck  *  has  recorded,  be  seen  to  be 
immovable.  This  instrument  reveals  very  often  the  ravages  the 
disease  has  committed  ;  and  we  are  thus  generally  enabled  to  form 
an  opinion  as  to  how  far  the  destruction  or  the  laryngeal  phthisis 
has  progressed,  and  which  of  the  soft  parts  as  well  as  of  the  car- 
tilages are  involved.  Leaving  out  the  frequent  perichondritis  and 
caries  of  the  cartilages  which  follow  the  deposition  of  tubercle,  we 
find  in  laryngeal  phthisis  considerable  sw^elling  of  the  epiglottis, 
and  often  semi-solid  pyriform  swellings  of  the  aryepiglottic  folds. 
The  thickening  is  more  regular  and  uniform  than  that  of  syphilis, 
and  the  ulcers  not  large  and  solid  as  in  this  affection,  but  small  and 
numerous,  and  both  vocal  cords  are  involved ;  while  in  this  as  in 
every  other  respect  syphilis  is  more  apt  to  be  local  and  unilateral. 
In  catarrhal  ulceration  the  ulcers  are  generally  very  superficial 
and  on  the  vocal  cords.  The  symptoms  attending  laryngeal 
phthisis  are  difficulty  in  breathing  and  in  swallowing,  local  pain 
and  soreness,  a  greatly-altered  or  a  lost  voice,  and  a  distressing, 
harsh  cough,  which  is  followed  at  times  by  purulent  expectoration. 
Besides,  we  find  the  manifestations  of  disease  of  the  lungs.  But 
it  occasionally  happens  that  we  encounter  tuberculous  ulcers  with 
abundant  bacilli,  in  which  no  lung-disease  existed  ;t  and  it  is  not 

*  Clinical  Eesearches,  trans.,  London,  1862. 
t  Canadian  Pract.,  1887. 


DISEASES   OF   THE   UPPER   AIR-PASSAGES.  253 

very  uncommon  to  find  the  tubercular  disease  of  the  larynx  pre- 
ceding that  of  the  lungs.  At  times  we  find  syphilitic  and  tuber- 
cular ulcers  in  combination. 

As  the  result  of  disease  of  the  cartilage  and  of  the  perichon- 
drium, especially  as  the  result  of  the  process  of  cicatrization,  we 
may  have  stricture  of  the  larynx  and  trachea  ;  for  this  is,  in  truth, 
the  most  common  origin  of  laryngeal  stenosis.  The  inspiration 
is  prolonged  and  noisy ;  the  voice  is  generally,  although  not  of 
necessity,  affected.  There  is  dyspnoea,  and  with  the  laryngoscope 
we  can  generally  see  how  greatly  the  calibre  of  the  tube  has  been 
encroached  upon.  Cicatrization  is  common  after  syphilis,  but 
Cohen's  case*  proves  that  it  may  occur  spontaneously  also  in 
tubercular  ulcerations. 

Ulcers  in  the  posterior  walls  of  the  larynx  give  rise,  as  a 
rule,  to  distressing  cough.  Respecting  tumors  of  the  larynx  and 
polypoid  growths  in  its  interior,  we  cannot  distinguish  them,  by 
their  symptoms  alone,  from  chronic  laryngitis.  Their  most  trust- 
worthy signs,  irrespective  of  the  cough  and  the  altered  voice,  are 
a  steadily  increasing  difficulty  in  breathing,  and  attacks  of  suffo- 
cation for  which  nothing  in  the  luno-s  or  heart  or  ffreat  vessels 
accounts.  The  detection,  at  the  seat  of  the  larynx,  of  a  growing 
tumor,  accompanied  by  a  severe  cough,  by  a  sanious  sputum,  by 
signs  of  destruction  of  tissue,  as  seen  with  the  laryngeal  mirror 
and  as  found  in  the  expectoration,  by  perichondritis  and  exfolia- 
tion of  the  laryngeal  cartilages,  by  hemorrhages,  and  by  emacia- 
tion, would,  in  addition  to  the  symptoms  just  enumerated,  war- 
rant the  diagnosis  of  cancer,  whether  or  not  much  pain  were 
present.  In  some  instances,  too,  gangrenous  pneumonia  occurs. 
Polyjyi  in  the  larynx  may  sometimes  be  seen  by  depressing  and* 
dragging  forward  the  tongue  until  the  epiglottis  is  brought  into 
view.  At  least  they  have  been  thus  discovered,  and  even  success- 
fully operated  upon.  But  as  regards  polypi,  or,  indeed,  any  form 
of  morbid  growth,  we  possess  in  the  laryngoscope  the  most  certain, 
usually  the  only  certain,  means  of  detecting  them,  and  even  of 
aiding  us  in  removing  them,  as  is  now  being  constantly  done. 
These  laryngeal  groAvths  vary  much  in  size  and  in  color  ;  they  are 
often  seated  at  the  anterior  free  edges  of  the  true  cords,  or  still 

*  Amer.  Journ.  Med.  Sci.,  Dec.  1888. 


254  MEDICAL   DIAGNOSIS. 

more  generally  just  above  or  just  below  their  origin,  and  are,  as 
a  rule,  reatlily  diseerned.  Sometimes  they  may  exist  for  years, 
merely  producing  changes  in  the  voice  and  some  cough,  but  no 
very  great  distress ;  or  they  may  lead  to  fits  of  sti-angulation 
and  to  sudden  death.  It  is  impossible  to  be  sure  of  their  nature 
without  repeatedly  examining  portions  of  them.  Pdj/illomas  are 
usually  cauliflower-like  or  in  bunches  ;  they  occupy  most  frequently 
the  vocal  cords,  while  sarcomas  are  oftenest  found  at  the  anterior 
portion  of  the  larynx.  Cysts  of  the  vocal  cords  are  much  rarer 
than  other  forms  of  growths ;  they  sometimes  rupture  sponta- 
neously, and  the  hoarse  voice  quickly  clears.* 

Before  concluding  these  remarks  on  diseases  of  the  larynx,  it 
may  be  thought  necessary  to  point  out  the  diiferences  between 
them  and  diseases  of  the  trachea.  But  affections  of  the  trachea 
need  not  be  separately  considered.  Lying  between  the  larynx 
and  the  bronchi,  the  trachea  commonly  shares  in  their  disorders. 
Thus,  we  have  seen  croup  to  be  a  malady  in  which  both  larynx 
and  trachea  are  involved.  Slight  inflammation  of  the  trachea 
occurs  constantly  in  slight  attacks  of  laryngitis  or  of  bronchitis. 
Ulcers  in  the  trachea  may  exist  without  ulceration  of  the  larynx ; 
but  then  they  usually  escape  detection.  Sometimes,  however,  they 
reveal  themselves  by  a  constant  pain  at  the  lower  portion  of  the 
neck  and  the  upper  part  of  the  sternum,  joined  to  all  the  symj)toms 
of  ulceration  of  the  larynx  except  the  impaired  voice.  Morbid 
growths,  too,  occur  in  the  trachea, — cancer,  carcinoma,  syphilitic 
growths, — as  they  do  in  the  larynx,  and  the  tube  may  be  altered 
in  form  and  in  structure.  Vegetations  also  form  in  the  trachea 
after  tracheotomy. f  AVe  can  make  use  of  the  laryngoscope  to 
assist  us  in  the  diagnosis  of  any  of  the  forms  of  tracheal  disease 
referred  to.  Yet  the  instrument  is  not  always  available ;  for  it  is 
only  under  favorable  circumstances  that  the  entire  extent  of  the 
trachea  can  be  seen. 

In  narrowing  of  the  trachea  the  bronchial  tubes  are  also  at  the 
same  time  often  narrowed.  The  stenosis  may  be  caused  by  ex- 
ternal compression,  as  from  a  goitre,  from  an  aneurism,  or  from  a 

*  Heinze,  Archives  of  Laryngology,  New  York,  1880. 

f  See  cases  collected  by  Petel,  Des  Polypes  de  la  Trachee,  Paris,  1879. 


DISEASES    OP   THE    UPPER    AIR-PASSAGES.  255 

mediastinal  tumor;  or  the  constriction  may  be  due  to  some  cause, 
such  as  new  formations,  in  the  walls  of  the  tubes.  The  chief 
symptoms  are  the  same  in  either  case ;  and  they  are,  long-drawn- 
out  respiratory  acts,  noisy  breathing,  especially  in  paroxysms, 
dyspnoea,  particularly  marked  in  inspiration,  epigastric  retraction, 
feebleness  or  absence  of  vesicular  murmur,  with  clear  pulmonary 
resonance,  loud  wheezing  heard  with  the  stethoscope  at  or  near 
the  place  of  constriction,  and  voice  slightly,  if  at  all,  impaired. 
This,  the  normal  appearance  of  the  larynx  as  shown  by  the  laryn- 
goscope, and  the  almost  imj)erceptible  motion  of  the  windpipe 
during  breathing,*  are  of  great  value  in  distinguishing  a  tra- 
cheal from  a  laryngeal  stenosis.  A  bronchial  stenosis  is  chiefly 
discriminated  by  the  signs  of  the  constriction  being  one-sided,  and 
attended  with  marked  thrill  of  the  thoracic  wall  of  the  aifected 
side,  and  with  louds  sounds  issuing  from  it,  loud  enough  to  be 
heard  at  a  distance. 

*  Gerliardt;  also  Eiegel,  in  Ziemssen's  Cj^clopaadia. 


CHAPTER   IV. 

DISEASES   OE   THE    CHEST. 

An  examination  of  the  diseases  of  the  chest  must  be  prefaced 
by  a  description  of  the  methods  of  investigation  which  have  given 
to  their  diagnosis  such  certainty.  The  same  methods  may  be  ap- 
plied in  the  study  of  the  maladies  of  other  parts  of  the  body,  but 
thev  are  of  special  service  in  the  recognition  of  thoracic  disorders, 
and  will  be  here,  therefore,  most  appropriately  considered. 

The  discrimination  of  disease  by  the  eye,  the  ear,  the  touch,  in 
fact  by  the  direct  aid  of  the  senses,  is  called  physical  dingnosis ; 
the  signs  thus  ascertained  are  connected  M'ith  perceptible  altera- 
tions in  the  material  properties  or  physical  nature  of  structures, — 
such  as  alterations  in  their  form,  their  density,  or  their  sounds, — 
and  are  known  as  physical  signs. 

Phvsical  signs  are,  then,  the  exponents  of  physical  conditions, 
and  of  nothing  more.  But  as  the  same  physical  conditions  may 
occur  in  various  diseases,  so  may  the  same  physical  signs  occur  in 
various  diseases.  An  isolated  sign  is,  therefore,  not  diagnostic  of 
any  particular  malady.  It  reveals  usually  an  anatomical  change  ; 
but  it  does  not  determine  the  disorder  occasioning  this  change. 
The  tendency  to  ascribe  to  each  thoracic  affection,  and  even  to 
each  stage  of  an  affection,  a  pathognomonic  sign,  has  greatly  re- 
tarded the  usefulness  of  physical  exploration.  By  presenting  a 
never-ending  list  of  specific  signs,  it  has  frightened  many  from 
attempting  to  become  acquainted  with  the  most  serviceable  of  all 
the  means  of  diagnosis,  and  many  more,  by  the  unnecessary  compli- 
cations introduced,  have  been  disheartened  at  the  very  threshold 
of  their  studies.  The  subject  may  be  much  simplified  by  laying 
less  stress  on  individual  signs,  and  by  grouping  them  togethei* 
according  as  their  association  becomes  distinctive. of  certain  well- 
marked  physical  states.  JNIorbid  anatomy  then  steps  in  with  its 
teachings,  and  tells  us  in  what  diseases  these  states  are  commonly 
25G 


DISEASES   OF   THE   CHEST.  257 

found.  It  is  in  conformity  with  these  views  that  I  shall  at- 
tempt, in  the  following  pages,  to  delineate  the  signs  of  thoracic 
affections. 

But  physical  signs  cannot  be  acquired  from  books ;  they  must 
be  learned  at  the  bedside.  Their  value  can  be  ascertained  by 
reading ;  yet  to  distinguish  them  with  readiness  requires  constant 
cultivation  of  the  eye,  of  the  ear,  and  of  the  sense  of  touch.  And 
it  is  of  great  importance  to  have  clear  ideas  regarding  the  structure 
of  the  parts  to  be  investigated,  and  of  their  action  in  health.  It 
must,  for  instance,  be  borne  in  mind  that  the  lung  is  covered  by  a 
serous  investment ;  and  that  it  consists  of  tubes  more  or  less  rigid, 
the  bronchial  tubes,  with  their  numerous  ramifications,  and  of  their 
termination  in  an  elastic  parenchyma,  the  air-vesicles,  or  the  pul- 
monary tissue  proper.  It  must  further  be  borne  in  mind  that  the 
organ  is  separated  into  lobes,  and  contains  air  which  is  constantly 
shifting,  and  that  locked  up  with  the  lungs  in  the  same  cavity  is 
the  main  organ  of  circulation. 

For  the  sake  of  convenience,  the  surface  of  the  chest  has  been 
mapped  out  into  regions.  Various  arrangements  of  these  have 
been  made  by  different  authors.  The  simplest  division  of  the 
chest  is  into  anterior,  posterior,  and  lateral  surfaces.  The  regions 
into  which  the  anterior  surface  may,  for  practical  uses,  be  sub- 
divided, are  an  upper  region,  extending  from  just  above  the  clav- 
icle to  the  fourth  rib,  and  a  lower  region,  from  the  fourth  rib 
downward.  Posteriorly,  also,  there  are  an  upper  and  a  lower 
part  of  the  chest  to  be  specially  examined.  It  is  hardly  necessary 
to  say  that  all  these  regions  are  double, — the  same  on  each  side  of 
the  chest.  Many  more  divisions  are  usually  made ;  but  they  are 
perplexing  to  the  student,  and  of  doubtful  value.  The  artificial 
boundaries  generally  laid  down  are,  indeed,  too  minute  and  yet 
not  minute  enough  ;  they  are  too  minute  for  ordinary  purposes, 
not  minute  enough  when  it  is  desirable  to  localize  a  physical  sign. 
Whenever  this  is  requisite,  instead  of  resorting  to  the  names  of 
the  regions  usually  employed,  I  think  it  preferable  to  designate 
the  seat  of  the  sign  with  reference  to  some  fixed  anatomical  point. 
This  may  be  done  for  the  anterior  part  of  the  chest  by  indicating 
the  distance  above  or  below  the  clavicle,  or  near  what  part  of  the 
sternum,  or  at  which  rib,  or  spreading  over  how  many  intercostal 
spaces,  the  sign  in  question  is  perceived.    At  the  posterior  part  of 

17 


258  MEDICAL   DIAGNOSIS. 

the  chest,  the  spinous  ridge  of  the  scapula,  its  lower  angle,  and 
the  spinal  column,  serve  as  landmarks.  For  most  clinical  pur- 
poses, it  is  only  needed  to  study  the  region"  above  the  spinous 
process  of  the  scapula,  as  separate  from  the  space  below.  But 
in  some  instances  it  may  be  necessary  to  notice  the  region  between 
the  scapulae  (inter-scapular)  or  that  extending  from  the  lower 
angle  of  the  bone  to  the  limits  of  the  chest  (infra-scaj)ular). 

Let  us  now  examine  the  different  methods  of  physical  diagnosis, 
and  particularly  in  their  relation  to  pulmonary  diseases. 


SECTION   I. 

DISEASES   OF   THE    LUXGS. 

The  Different  Methods  of  Physical  Diagnosis,  and  the 
Physical  Signs  of  Pulmonary  Diseases. 

INSPECTION. 

If  the  chest  be  examined  with  the  eye,  we  obtain  an  idea  of  its 
form,  size,  and  movements.  In  health  this  inspection  shows  us 
that  the  two  sides  of  the  chest  are,  to  a  great  extent,  symmetrical  in 
form,  as  w^ell  as  in  size  and  in  movement.  Both  sides  rise  equally 
during  inspiration  and  sink  equally  during  exjjiration.  On  both 
sides  the  motion  of  inspiration  is  longer  than  that  of  expiration, 
and  the  pause  between  them  extremely  slight. 

This  respiratory  movement  is  visible  over  the  whole  thorax. 
In  males  it  is  most  distinct  at  the  lower  portions  of  the  chest ; 
in  females  it  is  most  discernible  at  the  upper.  This  difference  in 
the  two  sexes  becomes  the  more  manifest,  the  more  hurried  the 
breathing.  In  healthy  adults  the  lungs  expand  with  regularity 
from  sixteen  to  twenty  times  in  a  minute.  In  certain  pulmonary 
affections,  especially  in  pneumonia,  the  number  of  respirations 
often  exceeds  fifty  in  a  minute.  But  hurried  breathing  and 
changed  movements  of  the  thorax  occur  independently  of  diseases 
of  the  lung.  The  heaving  of  the  chest  in  an  hysterical  paroxysm 
is  a  sight  familiar  to  every  practitioner.     Where  the  diaphragm 


DISEASES    OF    THE    LUNGS.  259 

does  not  descend,  as  in  consequence  of  peritonitis  or  of  abdominal 
dropsy  or  of  tumors,  the  breathing  is  much  more  rapid,  and  is 
perceptible  at  the  upper  parts  of  the  chest.  Again,  the  thoracic 
movements  may  be  distinct  on  one  side  and  hardly  noticeable  on 
the  other,  as  in  pleurisy  or  in  pneumothorax.  Lastly,  as  happens 
in  some  cerebral  lesions,  the  motions  of  the  chest  may  be  very 
slow  and  labored,  or  irregular,  or  they  may  have  apparently 
ceased,  and  the  breathing  be  altogether  abdominal. 

The  form  of  the  chest  is  sometimes  strikingly  altered  by  dis- 
ease. Congenital  malformations,  imperfect  development,  and  cur- 
vatures of  the  spine  modify  it ;  so  do  intra-thoracic  affections. 
Frequently  the  chest  presents  a  retracted  or  an  expanded  look. 
Retraction  denotes  diminished  size  of  the  lung,  and,  if  one-sided, 
is  usually  indicative  either  of  chronic  changes  in  the  lung-tissue, 
as  in  chronic  pneumonia  or  in  the  forms  of  phthisis,  or  of  false 
membranes  which  bind  down  the  lung ;  or  it  is  found  in  a  very 
marked  manner  in  empyema  with  external  opening.  Expansion 
of  the  chest  is  met  with  in  emphysema,  in  pneumothorax,  and 
in  pleuritic  effusion.  A  local  or  partial  expansion,  or  bulging, 
may  be  encountered  in  the  latter  disease,  or  it  may  depend  on 
thoracic  tumors,  on  pericardial  effusions,  or  on  hypertrophy  of 
the  heart. 

The  size  of  the  chest  can  be  only  approximatively  judged  of 
by  the  eye.  Where  accuracy  is  necessary,  measurements  must 
be  resorted  to. 

MENSURATIOlSr. 

To  measure  the  circumference  of  the  chest  or  of  the  abdomen, 
or  to  ascertain  the  distance  from  one  portion  of  the  surface  to 
the  other,  a  graduated  tape  is  all  that  is  required.  To  attain  the 
former  object,  the  spinous  process  of  a  vertebra  is  chosen  as  a 
fixed  point,  and  the  tape  is  thence  passed  round  the  body  to  the 
median  line,  first  on  one  side,  then  on  the  other,  taking  care  that 
it  be  applied  evenly  to  the  skin,  and  that  the  level  of  the  measure- 
ment be  the  same  on  both  sides.  This  level,  if  the  examination 
be  recorded,  should  always  be  noted,  that  we  may  have  a  uniform 
standard  of  comparison.  And  for  the  same  reason  it  is  best  to 
adopt  the  plan  of  making  our  measurements  as  nearly  as  pos- 
sible on  the  same  line :  for  example,  in  determining  the  circular 


260 


MEDICAL    DIAGNOSIS. 


Fig.  13. 


width  of  the  thorax,  we  can,  as  a  rule,  select  a  line  immediately 
above  the  nipple,  or  draw  the  tape  around  the  chest  toward  the 
sixth  eosto-sterual  joint,  and,  therefore,  on  the  level  of  the  ^Ixth 
rib  near  its  attachment  to  the  cartilage.  We  measure  thus  the 
width  of  the  chest ;  if  we  wish  to  obtain  the  longitudinal  diam- 
eter, the  line  from  the  clavicle  to  the  base  of  the  chest  is  taken. 
AYhere  the  chest  is  deformed,  Woillez's  cyrtometer  may  benised 
in  place  of  the  tape. 

In  estimating  the  size  of  the  chest  in  disease,  it  must  be  borne 
in  mind  that  even  in  health  its  two  sides  vary  widely.  The  half- 
circle  on  the  right  side  is,  in  right- 
handed  persons,  at  least  half  an 
inch  larger  than  the  half-circle 
on  the  left.  But  the  measure- 
ments, to  be  trusted,  must  be 
performed  while  the  patient  is 
holding  his  breath  in  expiration. 
In  inspiration  the  girth  of  the 
chest  is  increased  fully  three 
inches.  In  well-developed  men 
it  measures  at  the  upper  part 
about  thirty-three  to  thirty-four 
inches  during  expiration. 

If  it  be  desirable  to  ascertain 
in  how  far  the  respiratory  acts 
modify  the  dimensions  of  the 
chest  or  of  the  abdomen,  this  may  be  readily  effected  by  the  in- 
genious "  chest-measurer"  of  Sibson,  or  by  the  "  stethometer"  of 
Quain  or  of  Carroll,*  all  of  which  instruments  register  accurately 
the  movements  of  breathing ;  or  the  respiratory  curves  can  be 
traced  and  studied  by  the  atmograph  of  Burdon  Sanderson,  or  by 
the  anapnograph,  an  instrument  made  use  of  by  Bergeon  and 
Kastus,  and  similar  to  the  sphygmograph,t  or  by  Eiegel's  double 
stethograph ;  or  the  curves  of  the  respiratory  movements  may  be 
seen  in  the  tracings  of  the  pneumograph  applied  to  the  chest.  Ran- 
some  has  called  attention  to  the  value  of  recording  the  exact  extent 


The  stethometer  of  Quain.  The  box  is 
placed  on  the  sternum,  and  the  string  cur- 
ried around  the  cliost.  One  revolut'on  of  tlie 
index,  whicli  is  moved  by  a  rack  attaclicd  to 
the  string,  indicates  an  inch  of  motion  in  tlie 
chest. 


*  New  York  Medical  Journal,  1868. 

f  Gazette  Hebdomadaire,  Ser.  2,  v.,  1868. 


DISEASES   OF   THE   LUNGS. 


261 


of  the  respiratory  movements  by  stethometry  as  a  means  of  prog- 
nosis in  chest  disease.* 

The  transverse  diameter — the  breadth — of  the  chest  may  be 
determined  by  means  of  a  pair  of  callipers,  arranged  specially  for 
the  purpose ;  and  the  curves  or  flatness  of  the  surface  may  be 
ascertained,  should  it  be  necessary,  by  Alison's  stetho-goniometer 
(Fig.  14);  but  it  is  rarely  necessary.     In  fact,  these  minute  meas- 


FiG.  14. 


The  stetho-goniometer  of  Scott  Alison. 


urements,  however  interesting  to  the  physiologist,  have,  as  yet,  not 
been  made  available  to  the  physician.  Inspection  teaches  us  the 
same  as  mensuration.  What  it  teaches  with  less  precision  can  be 
learned  for  purposes  of  diagnosis  with  a  graduated  tape. 

Mensuration  may  be  employed  not  only  to  judge  of  the  size  of 
the  chest  and  of  its  movements,  but  also  to  ascertain  the  amount 
of  air  which  is  received  into  the  lungs.  The  instrument  used 
for  this  object  is  the  spirometer,  an  invention  of  Dr.  John  Hut- 
chinson ;  and  since  his  time  numerous  modifications  of  the  instru- 
ment have  been  made :  for  instance,  the  ordinary  dry  and  the  wet 
gas-meter  have  been  adapted  to  the  purposes  of  spirometry,  and 
an  instrument  small  enough  to  be  carried  in  the  pocket  has  been 
suggested.  The  results  the  spirometer  has  yielded  are  of  value  in 
a  physiological  point  of  view ;  in  a  clinical,  there  are  too  many 
sources  of  fallacy  and  too  many  drawbacks  to  render  them  of  much 
importance ;  and  not  the  least  of  those  drawbacks  is,  that  it  takes 
considerable  practice  to  learn  how  to  blow.  The  spirometer  may 
indicate  that  a  large  quantity  of  air  enters  the  lungs,  and  thus  be- 
come a  rough  test  of  their  normal  condition.  But  when  less  air 
passes  into  the  organ  than  the  spirometric  standard  requires,  this 
leads  in  itself  to  no  conclusions ;   certainly  not  to  any  concerning 


*  Medico-Chirurgical  Transactions,  vol.  xlvi.,  1881. 


262  MEDICAL   DIAGNOSIS. 

the  disease  which  occasions  the  diminished  vital  capacity.  In  esti- 
mating results  arrived  at  by  the  spironietei",  it  must  be  remembered 
that  sex,  -sveight,  age,  and  height  have  to  be  taken  into  account. 
To  the  latter  Hutchinson  assigns  much  importance,  since  he  enun- 
ciates the  law  that  for  every  inch  above  five  feet,  eight  cubic  inches 
are  to  be  added  to  the  healthy  standard.  For  the  height  of  five 
feet,  the  breathing  volume  is  one  hundred  and  seventy-four  cubic 
inches.  But  these  calculations  are  not  exact ;  they  only  approxi- 
mate the  truth.  ISIoreover,  the  vital  capacity  may  be  increased 
by  practice,  with  the  spirometer  or  by  the  use  of  pneumatic  instru- 
ments designed  to  breathe  in  compressed  air  or  to  breathe  out  into 
rarefied  air. 

To  determine  both  the  expiratory  and  the  inspiratory  j)ower, 
the  hsemadynamometer  may  be  employed.  Hammond*  recom- 
mends the  use  of  the  instrument  in  the  examination  of  recruits. 
According  to  his  observations,  healthy  men  of  five  feet  eight  inches 
raise  the  column  of  mercury  about  two  inches  by  inspiration,  and 
about  three  inches  by  expiration. 

Waldenburg  measures  the  force  in  respiration  by  a  special  appa- 
ratus, and  has  introduced  pneumatometry  as  a  means  of  diagnosis. 
The  power  exerted  in  expiration  is  greater  than  in  inspiration.  In 
some  aifections  the  expiratory  pressure  is  largely  diminished,  as  in 
emphysema  and  asthma,  while  in  the  forms  of  phthisis  the  force 
of  inspiration  is  much  lessened. 

PALPATION. 

Palpation,  or  the  application  of  the  hand,  confirms  the  results 
obtained  by  inspection  and  mensuration  as  to  size,  form,  and 
movements.  It  may,  in  addition,  be  employed  to  determine  spots 
of  soreness,  the  density  and  condition  of  tumors,  the  state  of  the 
thoracic  walls,  the  frequency  of  the  breathing,  and  the  action  of 
the  heart.  The  hand  may  further  be  of  service  as  a  means  of  dis- 
tinguishing vibrations  produced  by  rhonchi,  rhonchal  fremitus,  or 
by  the  voice,  vocal  fremitus ;  or  it  may  detect  fluid  by  the  sense 
of  fluctuation  it  imparts,  or  a  roughened  serous  membrane  by  the 
friction  fremitus.  AVhen  both  fluid  and  air  are  present  in  a  large 
hollow  space,  by  shaking  the  patient  a  distinct  vibration  of  the 

*  Treatise  on  Hygiene,  Philadelphia,  1863. 


DISEASES   OF    THE    LUNGS. 


263 


parietes  is  felt,  accompanied  by  a  splashing  sound,  known  as  the 
Hippocratic  or  succussion  sound. 

Palpation  is  to  be  practised  by  applying  the  palmar  surface  of 
one  or  of  several  fingers  evenly,  and  without  too  much  pressure, 
on  the  part  to  be  examined. 

PEKCUSSION. 

By  percussing  or  striking  bodies  we  elicit  sounds  by  which  we 
judge  of  their  composition.  That  a  solid  body  emits  sounds  dif- 
ferent from  a  hollow  one,  has  been  familiar  to  every  artisan  from 
time  immemorial ;  but  the  application  of  this  well-known  fact  to 
the  study  of  the  diseases  of  the  human  frame  was  a  discovery  of 
Avenbrugger,  a  Viennese  physician  of  the  last  century.  He  and 
the  brilliant  editor  of  his  work,  Corvisart,  practised  percussion 
by  striking  directly  with  the  hand  over  the  organs  to  be  ex- 
plored ;  a  method  which,  although  serviceable  to  ascertain  marked 
differences,  or  to  obtain  an  idea  of  the  general  resonance  of  a  part, 
is  inferior  to  the  one  introduced  by  Piorry,  of  mediate  percussion. 
The  media  used  to  receive  the  blow  are  various  :  a  disk  or  plate  of 
ivory,  of  wood,  or  of  leather ;  a  piece  of  india-rubber;  or  the  middle 
finger  of  the  left  hand.  The  finger  answers  best  for  percussion  of 
the  chest;  for  abdominal  percussion  a  pleximeter  is  preferable. 

When  the  finger  is  employed,  it  ought  to  be  applied  with 
its    palmar    surface    firmly 

pressed    against    the   chest,  Fig.  15. 

and  as  parallel  as  possible 
to  the  ribs.  One  or  two 
fingers  of  the  other  hand 
may  then  be  used  to  tap 
with, — for  the  finger  is,  for 
ordinary  purposes,  better 
than  any  of  the  percus- 
sion hammers  invented, — 
the  greatest  attention  being 
paid  to  the  circumstance  that 

the  percussing  finger  strikes  perpendicularly,  whatever  pleximeter 
be  used,  and  not  slantingly,  as  is  too  generally  the  case.  The 
whole  movement  should  proceed  from  the  M-rist,  and  only  from 
the  wrist,  and  ought  not  to  be  too  rapid,  or  unequal,  or  of  great 


The  ploximeter  ;  about  natural  size.     It  may  be 
conveniently  made  of  hard  rubber. 


204  MEDICAL   DIAGNOSIS. 

force.  If  all  of  these  apparently  unimportant  points  are  attended 
to,  the  results  obtained  may  be  relied  upon  ;  if  not,  the  want  of 
manual  dexterity  invalidates  the  conclusions.  No  other  fault  is  so 
often  committed  by  the  beginner  as  that  of  raising  the  finger  used 
as  a  pleximeter  from  the  surface, — thus  obtaining  the  sound  of  the 
finger,  and  not  that  of  the  organ  he  wishes  to  percuss, — unless  it 
be  the  fault  of  striking  with  great  force,  as  if  the  object  were  to 
break  into  the  cavity  of  the  chest.  Forcible  percussion  is  of  use 
only  when  the  sound  of  deep-seated  organs  is  to  be  brought  out. 

The  main  sounds  elicited  by  percussion  may  be  designated  as 
dull,  clear,  and  tympanitic.  Of  course,  these,  like  all  other 
sounds,  may  differ  in  strength,  in  duration,  and  in  pitch. 

A  dull  sound  denotes  absence  of  air.  It  is  the  sound  both  of 
fluids  and  of  solids.  It  is,  thus,  the  sound  sent  forth  from  the 
airless  viscera, — from  the  liver,  spleen,  and  heart.  AVhen  it 
takes  the  place  of  the  pulmonary  sound,  it  bespeaks  consolida- 
tion, from  whatever  cause  induced,  or  the  presence  of  something 
which  checks  the  normal  vibrations  of  the  lung-texture.  Dulness 
is  always  associated  with  an  increased  sense  of  resistance  to  the 
percussing  finger,  and  over  parts  emitting  it  the  vibrations  of  the 
tuning-fork,  which  Bass  has  introduced  into  diagnosis,  are  weak, 
while  they  are  loud  over  normal  pulmonary  structure. 

A  clear  sound  is  produced  by  a  series  of  marked  and  un- 
hindered vibrations  which  are  emitted  from  a  substance  containing 
air.  As  thus  defined,  a  clear  sound  evidently  is  yielded  by  per- 
cussing any  air-containing  organ.  But  custom  has  restricted  the 
employment  of  the  term  clear  to  denote  the  peculiar  resonance 
obtained  by  striking  over  pulmonary  tissue.  When,  therefore,  a 
clear  sound  is  spoken  of,  it  means  a  sound  having  the  nature  of 
that  of  the  lungs,  or  of  normal  vesicular  or  pulmonary  resonance. 
A  resonance  analogous  to  the  vesicular  resonance  may  be  obtained, 
Flint  points  out,  by  percussing  a  loaf  of  bread. 

A  tympanitic  sound,  on  the  other  hand,  is  a  non- vesicular  sound, 
having  the  character  of  that  of  the  intestine.  Wherever  heard,  it 
indicates  the  presence  of  quantities  of  air  in  conditions  similar  to 
that  contained  in  the  intestine, — namely,  enclosed  in  walls  which 
are  yielding,  but  neither  tense  nor  very  thick.  When  elicited  over 
the  chest,  it  may  be  only  the  transmitted  sound  of  a  distended 
stomach  or  colon.     But  generally  a  tympanitic  sound  over  the 


DISEASES    OF    THE    LUNGS. 


265 


seat  of  the  lungs  is  expressive  of  em- 
physema or  of  pneumothorax,  or  some- 
times of  a  cavity  or  of  oedema  of  the 
lungs.  Again,  as  Skoda  has  taught 
us,  it  occurs  in  moderate  pleural  effu- 
sions above  the  level  of  the  liquid. 
Many  find  difficulty  in  distinguishing 
between  the  clear  sound  of  the  pulmo- 
nary tissue  and  the  tympanitic  sound. 
The  more  ringing  character  of  the  lat- 
ter, and  its  higher  pitch,  constitute  its 
essential  properties. 

As  modifications  of  the  tympanitic 
sound  may  be  viewed  the  amphoric  or 
metallic  sound,  and  the  cracked-pot  or 
cracked-metal  sound.  The  first  of  these 
is  a  concentrated  tympanitic  sound  of 
raised  pitch,  and  denotes  a  large  cavity 
with  firm,  elastic  walls.  The  second 
is  not  unfrequently  found  associated 
with  it.  It  requires  for  its  develop- 
ment a  strong,  abrupt  blow  of  the  per- 
cussing finger  while  the  patient  keeps 
his  mouth  open.  The  condition  most 
usually  occasioning  the  sound  is  a  cav- 
ity communicating  with  a  bronchial 
tube.  It  is  also  met  with  uncombined 
with  an  excavation,  as  in  the  bronchitis 
of  children,  in  pleurisy  above  the  seat 
of  eifusion,  near  a  pericardial  exuda- 
tion, in  emphysema,  and  in  certain  in- 
stances of  pneumothorax.  Indeed,  any 
disorder  in  which  the  chest-Myalls  re- 
main very  yielding,  and  in  which  a 
certain  amount  of  air  contained  in  the 


Fia.  10. 


MM 


Fig.  16. — A  serviceablp  model  of  a  percussion  hammer; 
not  quite  natural  size.  The  india-rublievis  screwed  to  the 
ring,  which  has  a  diameter  of  five-eiglitlis  to  thi-ee-quarters 
of  an  inch.  The  metallic  rin.c;  is  attached  to  a  steel  stem 
with  a  very  decided  siirini;  Tlie  pointed  portion  of  the 
india-rubber  is  used  to  strike  with  on  the  pleximeter. 


266  MEDICAL   DIAGNOSIS. 

lung  or  pleura  and  in  uninterrupted  connection  with  the  external 
air  is,  bv  sudden  ])ereussion,  forced  into  a  bronchial  tube,  will 
occasion  this  cracked-metal  sound. 

In  addition  to  the  character  of  all  these  sounds,  we  study  their 
degree,  or  amount  of  fulness :  such  changes  as  are  expressed  by 
"  more  or  less,"  ''  diminished  or  increased."  Thus,  a  clear  sound 
may  be  increased,  owing  to  stronger  vibrations  and  a  larger  quan- 
tity of  air,  yet  not  lose  its  distinctive  pulmonary  character,  as 
happens  often,  for  instance,  when  the  air-cells  are  dilated ;  the 
sound  of  the  large  intestine  is  fuller,  more  tympanitic,  than  that 
of  the  small  intestine,  and  so  forth. 

With  changes  in  fulness  or  volume  of  sound  go  hand  in  hand 
changes  in  its  jj/fc/?.  Increased  volume  is  linked  to  lowered 
pitch,  diminished  volume  to  higher  pitch  ;  but  so  is  increased 
tension. 

To  sum  up  the  chief  results  of  percussion,  as  above  described  : 

Quality,  or  Character  of  Sound. 
Clear  : — Presence  of  air, — as  in  the  lung-tissue. 
Dull  : — Solidification  or  compression. 

Tympanitic  : — Certain  amount  of  air  enclosed  in  a  structure  or  cavity  the 
walls  of  which  are  not  too  tense. 
Metallic : — Large  hollow  space,  with  firm  but  elastic  walls. 
Ch-acked-metal  sound: — Usually  a  cavity  communicating  with  a  bron- 
chus. 

Degree,  or  Intensity. 
Any  of  the  sounds  mentioned  may  be  diminisJicd  or  increased  in  intensity 
as  the  conditions  which  produce  them  are  modified. 

Pitch. 
Heightened  or  lowered  as  amount  of  air  or  as  tension  is  altered. 

If  it  be  desirable  to  obtain  a  more  distinct  idea  of  the  sound 
than  can  be  done  by  the  ordinary  method  of  practising  percus- 
sion, it  may  be  accomplished  by  resorting  to  auscultatory  percus- 
sion,— a  method  which  was  introduced  by  Cammann  and  Clark, 
and  which  consists  in  listening,  with  a  stethoscope  applied  to  the 
parietes,  to  the  sounds  elicited  by  percussion.  It  is  a  means  of 
determining  with  accuracy  the  boundaries  of  various  organs,  as  of 
those  of  the  lungs  or  heart,  or  of  the  liver  or  spleen,  and  yields 


DISEASES   OF   THE   LUNGS.  267 

particularly  exact  results  when  carried  out  with  the  d(juljle  steth- 
oscope. 

The  percussion  sound  will  also  be  found  to  vary  with  the  re- 
spiratory movement,  and  useful  information  may  be  obtained  by 
the  appreciation  of  the  note  elicited  by  percussion  while  the  breath 
is  held  after  a  full  inspiration  or  in  a  prolonged  expiration, — a 
method  of  diagnosis  for  which  I  have  proposed  the  name  of 
7'espiratory  percussion.  * 

As  a  standard  for  comparison  in  disease,  the  results  of  respira- 
tory percussion  in  health  must  be  carefully  determined.  It  will 
be  found  that  in  the  normal  chest,  anteriorly,  a  full  held  inspira- 
tion increases  the  resonance,  makes  the  sound  fuller,  and  raises 
the  pitch  ;  but,  making  allowance  for  the  cardiac  region,  the  reso- 
nance below  the  apices  is  relatively  less  increased  on  the  left  than 
on  the  right  side. 

Posteriori}',  we  find  in  the  supra-spinous  fossse,  and  on  a  line 
toward  the  spine,  that  a  full  inspiration  makes  the  percussion 
sound  fuller  and  raises  the  pitch,  especially  on  the  right  side.  In 
the  inter-scapular  and  infra-scapular  regions  the  tone  on  gentle 
percussion  is  distinctly  pulmonary  and  the  pitch  moderately  high. 
On  the  left  side  an  admixture  of  tympanitic  resonance  may  be 
detected,  particularly  in  the  infra-scapular  region.  The  pitch  is 
somewhat  lower  in  the  left  scapular  and  infra-scapular  region 
than  in  the  right.  A  full  held  inspiration  elevates  the  pitch, 
increases  the  resonance  very  much,  and  makes  the  difference 
between  the  sides  less  apparent. 

A  held  and  complete  expiration  greatly  lessens  resonance  and 
lowers  the  pitch  on  percussion. 

The  quality  of  the  percussion  note  during  an  arrested  respira- 
tory movement  is  but  little  changed ;  perhaps  it  is  somewhat  less 
soft,  corresponding  to  the  marked  resistance  to  the  percussing 
finger.  In  a  held  inspiration,  nevertheless,  we  obtain  the  idea 
of  a  greater  mass  of  tone ;  in  a  held  expiration,  the  reverse.  In- 
crease in  volume  of  percussion  note  accompanies,  contrary  to  our 
usual  experience,  heightened  pitch ;  and  this  is  more  especially 
noticed  in  connection  with  the  slight  change  in  quality  above 


*  Amer.  Journ.  Med.  Sci.,  July,  1875;  see  also  Friedreich,  Deutsches  Ar- 
chiv  fiir  Klin.  JVIed.,  Bd.  xxvi. 


268  MEDICAL    DIAGNOSIS. 

mentioned.  This  anomaly  is  probably  duo  to  the  altered  tension 
of  the  structures,  both  lung-texture  and  ehest-walls,  during  held 
respiratory  movement. 

These  are  the  chief  facts  connected  with  a  study  of  respiratory 
percussion  in  health.  The  application  to  disease  is  manifold,  as 
we  shall  find  in  the  study  of  emphysema,  of  phthisis,  of  pleurisy, 
and  of  pneumothorax. 

Percwstiion  of  the  Healthy  Chest. 

The  sound  elicited  by  striking  a  healthy  chest  diifers  in  accord- 
ance -with  the  part  percussed.  The  anterior  portion  renders  a 
clearer  sound  than  the  posterior,  on  account  of  the  slighter  thick- 
ness of  the  thoracic  walls.  But  the  pulmonary  resonance  is  not, 
even  anteriorly,  alike  at  all  parts.  The  portion  of  lung  above  the 
clavicle  yields  a  sound  which  becomes  somewhat  tympanitic  as  the 
trachea  is  approached.  Percussion  is  difficult  in  this  region,  as  it 
is  ahnost  impossible  to  apply  the  finger  or  pleximeter  properly  to 
the  surface ;  hence  arise  errors  in  diagnosis  if  too  much  value  be 
attached  to  trifling;  differences  bet'\\^een  the  two  sides.  Over  the 
clavicle  the  sound  sent  forth  is  clear  and  pulmonary  at  the  centre 
of  the  bone  ;  at  its  scapular  extremity  it  is  duller ;  toward  the 
sternum  it  becomes  of  higher  pitch,  and  mixed  with  the  sound 
of  the  bone.  In  the  region  bounded  above  by  the  clavicle,  and 
below  by  the  upper  margin  of  the  fourth  rib,  the  resonance  is 
very  marked.  In  fact,  the  sound  of  this  region  may  be  taken  as 
a  type  of  the  pulmonary  sound  :  it  is  very  clear  and  distinct,  and 
but  little  resistance  is  offered  to  the  percussing  finger.  Yet  a 
slight  disparity  generally  exists  between  the  two  sides.  On  the 
right  side  the  sound  is  somewhat  less  clear,  shorter,  and  of  a 
higher  pitch,  than  on  the  left.  From  the  fourth  rib  downward, 
on  the  right  side,  the  resonance  of  the  lung,  on  strong  percussion, 
is  found  to  be  slightly  deadened  ;  near  the  sixth  rib  the  perfectly 
dull  sound  indicates  that  the  liver  has  been  reached.  On  the 
right  side,  during  full  inspiration,  the  liver  is  pushed  downward 
for  the  space  of  an  inch  or  more ;  and  the  dull  sound  on  percus- 
sion begins,  therefore,  lower  down,  and  on  a  line  corresponding  to 
the  displacement  of  the  organ. 

On  the  left  side  the  heart  deadens  the  sound  from  the  fourth  to 
the  sixth  rib,  and,  in  a  transverse  direction,  from  the  sternum  to 


DISEASES   OF   THE   LUNGS.  269 

the  nipple.  This  dull  sound  is  lessened  in  extent  during  inspira- 
tion, and  in  cases  of  emphysema ;  indeed,  under  any  circumstances 
in  which  the  lung  more  completely  covers  the  heart.  Lower  down, 
owino-  to  the  liver  reaching  over  to  the  left  side,  and  to  the  pres- 
ence of  the  spleen  and  a  portion  of  the  stomach,  the  sound  ren- 
dered on  percussion  consists  of  a  mixture  of  the  dull  sound  of  the 
solid  viscera  and  of  the  clear  sound  of  the  lung  with  the  tympa- 
nitic sound  of  the  stomach.  The  latter  character  of  sound  pre- 
dominates when  the  stomach  is  empty.  Over  the  upper  part  of 
the  sternum,  to  the  third  rib,  the  percussion  sound  is  slightly 
tympanitic;  at  the  lower  part,  the  heart  and  liver  cause  this 
tympanitic  or  tubular  character  of  sound  to  give  way  to  a  dull 
sound. 

Position  exerts  some  influence  on  the  results  of  percussion.  On 
exchanging  the  recumbent  for  the  erect  posture,  the  pitch  of  the 
sound  on  the  front  of  the  chest  is  raised. 

At  the  posterior  portion  of  the  chest  the  sound  varies  mate- 
rially according  to  the  part  percussed.  Directly  on  the  scapulae 
the  sound  is  duller  than  between  the  bones,  or  than  below  their 
inferior  angles.  Beneath  the  scapulae  a  clear  sound  is  emitted 
as  far  as  the  low^er  border  of  the  tenth  rib ;  here,  on  the  right 
side,  the  clulness  of  the  liver  begins.  Strong  percussion,  however, 
causes  the  dulness  to  become  manifest  higher  up.  On  the  left 
side,  below  the  angle  of  the  scapula,  the  percussion  sound  may 
be  tymj^anitic  if  the  intestine  be  distended  ;  or  it  may  be  ren- 
dered slightly  dull  by  the  spleen.  In  and  under  the  axilla  the 
sound  is  very  clear.  But  on  the  right  side,  at  the  lower  border 
of  the  sixth  rib,  dulness  becomes  perceptible ;  at  a  correspond- 
ing situation  on  the  left  side,  the  sound  is  clear  or  tympanitic 
from  distention  of  the  stomach ;  and  at  the  ninth  or  tenth  rib, 
dulness  and  a  sense  of  resistance  to  the  finger  disclose  the  pres- 
ence of  the  spleen. 

AUSCULTATION. 

Auscultation,  or  listening  to  sounds,  informs  us  of  the  play 
of  organs,  and  furnishes  us  with  the  most  trustworthy  means  of 
studying  their  action.  It  is  of  signal  service  in  affections  of  the 
chest.  Indeed,  any  one  who  reflects  upon  the  certainty  with  which 
eases  of  thoracic  disease,  which  would  have  set  at  defiance  the  skill 


270 


MEDICAL    DIAGNOSIS. 


Fig 


Fig.  18. 


T 


of  a  Sydenham  or  a  Cullen,  are  now  capable  of  being  detected, 
even  by  comparative  tyros,  will  gladly  acknowledge  the  heavy 
debt  of  gratitude  we  owe  to  the  genius  of  Laennec. 

The  method  he  practised  was  the  mediate,  or  by  the  stethoscope. 
Another  metliod  has  since  his  time  grown  up, — the  immediate,  or 
the  direct  application  of  the  ear  to  the  chest.  For  ordinary  pur- 
poses, this  is  the  best ;  but  where  it  is  desirable  to  analyze  cir- 
cumscribed sounds,  as  in  diseases  of  the  heart,  the  stethoscope  is 
preferable. 

Stethoscopes  are  made  of  various  materials  and  of  different 
shapes.  One  of  moderate  length,  with  an  ear-piece  which  fits  the 
pavilion  of  the  ear,  and  with  the  extremity  not  too  much  expanded, 
is  to  be  preferred.  The  material 
is  of  less  importance.  I  like  best 
those  of  ffun-metal,  introduced  bv 
Hawksley.  Of  late  years  double 
stethoscopes  have  been  muclr  em- 
ployed. The  instrument  invented 
by  Cammann,  of  New  York,  con- 
sists of  two  tubes,  the  extremities 
of  which  are  placed  into  the  ears. 
It  has  since  been  modified  by 
making  the  tubes  attached  to  the 
ear-pieces  of  flexible  rubber.  It 
possesses  the  advantage  of  render- 
ing sounds  louder :  its  great  draw- 
back is  that  it  indiscriminately  intensifies  all 
sounds,  whether  in  the  chest  or  not,  and  its 
use  is,  therefore,  at  first  confusing.  A  similar 
is  the  differential  stethoscope  of  Alison,  by  which  each  ear  receives 
simultaneously  the  sound  from  a  different  region. 

In  auscultating,  the  following  rules  are  to  be  borne  in  mind : 
1st.  Place  yourself  and  your  patient  in  a  position  which  is  the 
least  constraining  and  permits  of  the  most  accurate  application 
of  the  ear  or  stethoscope  to  the  surface.     Above  all,  avoid  stoop- 
ing, or  having  the  head  too  low. 

2d.   Let  the  chest  be  bare,  or,  what  is  better,  covered  only  with 
a  towel  or  a  thin  shirt. 

3d.  If  a  stethoscope  be  employed,  apply  it  closely  to  the  sur- 


Hawksley's     stethoscope, 
with   detached   ear-pieco. 


:ind  of  stethoscope 


DISEASES   OF   THE    LUNGS. 


271 


face,  but  abstain  from  pressing  with  it.  This  may  be  obviated 
by  steadying  the  instrument,  immediately  above  its  expanded 
extremity,  between  the  thumb  and  the  index  finger. 

4th.  Examine   repeatedly  the  different  portions  of  the  chest, 
and  compare  them  with  one  another  while  the  patient  is  breathing 


Fig.  19. 


FiQ.  20. 


Alison's  differential  stethoscope. 


The  double  stethoscope. 


quietly.  Making  him  cough  or  draw  a  full  breath  is,  at  times, 
of  service ;  especially  the  former,  when  he  does  not  know  how  t,o 
breathe. 

Sounds  of  Respiration  in  Health  and  in  Disease. 
The  ear  applied  over  the  trachea  of  a  healthy  person,  and  sub- 
sequently over  the  lungs,  discriminates   two   dissimilar   sounds, 
which  may  be  severally  taken  as  starting-points. 


272  MEDICAL    DIAGNOSIS. 

The  first  is  plainly  blowing,  both  in  inspiration  and  in  expira- 
tion. It  is  heard  over  the  larvnx  and  traehea  ;  and  in  a  sliyhtlv 
modified  form,  as  a  less  intense  and  hollow  sound,  at  the  upper 
part  of  the  sternum  ;  and  sometimes,  owing  to  the  closeness  of 
large  bronehial  tubes  to  the  surface,  it  is  perceived  between  the 
scapula?,  on  a  level  Avith  their  ridges.  It  is  occasioned  by  air 
passing  through  the  tubes,  and  is  known  as  the  tubular  or  the 
bronchial  sound. 

The  sound  over  the  lung-tissue  is  different:  it  is  nuieh  softer, 
more  gradually  formed,  of  lower  pitch,  mainly  inspiratory,  and 
almost  immediately  followed  by  a  shorter  and  far  less  distinct  ex- 
piration. This  is  the  vesicular  murmur, — produced  in  the  finest 
bronchial  tubes  and  air-cells  by  their  expansion  and  contraction. 
The  expansion  gives  rise  to  the  distinct  breezy  inspiration  ;  the 
noiseless  contraction  of  the  elastic  walls  of  the  vesicles  and  the 
passage  of  air  back  into  the  smaller  bronchial  tubes  cause  the 
short,  indistinct,  sometimes  almost  inaudible  expiration.  But  the 
vesicular  murmur  is  not  exactly  alike  at  different  parts  of  the 
lungs.  It  is,  as  a  rule,  better  marked  over  the  upper  lobes  than 
over  the  lower,  and  more  clearly  defined  anteriorly  than  pos- 
teriorly. Nor  is  the  sound  of  the  two  lungs  precisely  the  same ; 
a  disparity  may  generally  be  noticed  at  the  apices.  ]\Iost  authors 
describe  the  vesicular  murmur  as  more  intense  on  the  right  side. 
Investigations  instituted  to  determine  this  point  lead  me  to  agree 
with  Flint  that  the  reverse  is  the  case.  More  expiration,  a  higher 
pitch,  therefore  more  of  the  bronchial  element,  is  presented  by  the 
upper  portion  of  the  right  lung.  But  a  stronger,  more  vesicular 
inspiration  belongs  to  the  left  lung. 

The  murmur  of  the  air-cells,  then,  is  the  sound  which  the  ear 
encounters  when  it  is  placed  over  the  greater  part  of  the  chest. 
Bronchial  respiration  is  constantly  engendered  in  the  tubes  of  the 
lung ;  but,  either  because  it  is  overpowered  by  the  sounds  of  the 
myriads  of  expanding  air-vesicles,  or  because  the  pulmonary  tissue 
is  a  bad  conductor  for  a  deep-seated  sound,  or  perhaps  because 
the  sound  requires  consolidated  tissue  for  its  perfect  production, 
bronchial  breathing  is  not  heard  over  the  chest,  except  at  the  very 
limited  space  indicated,  imless  the  action  of  the  air-vesicles  have 
been  suppressed. 

Disease,  however,  gives  rise  not  only  to  changes  as  absolute  as 


DISEASES    OF   THE    LUNGS.  273 

suppression  of  the  vesicular  murmur  and  its  substitution  by  a 
bronchial  respiration,  but  also  to  certain  modifications  oftlic  mur- 
mur, which  serve  as  valuable  guides  in  diagnosis.  Thus,  the 
vesicular  murmur  may  be  abnormal  in  its  intensity,  or  in  its 
rhythm,  or  it  may  have  lost  some  of  the  elements  of  its  distinctive 
character,  such  as  its  softness. 

Changes  in  the  Vesicular  Murmur.— The  changes  of 
the  murmur   which   are  of  importance  may  be  summed  up  as 

follows : 

r  Increased,  or  puerile  breathing  ; 
Alteration  in  Intensity...-!   Diminished,  or  feeble  respiration  ; 

'-  Absent  respiration. 

{Divided  and  jerking  respii'ation  ; 
Alteration  of  length  of  expiration  relatively 
to  inspiration. 

Alteration  in  Character..  <    Harsh  respiration. 

Intensity. — An  increase  of  the  vesicular  murmur  is  called  sup- 
plementary respiration,  or,  from  its  resemblance  to  the  breathing 
of  children,  puerile  respiration.  It  depends  upon  an  increased 
action  of  the  air-vesicles ;  more  air,  or  air  with  greater  force, 
entering  them.  The  sound  is  simply  a  loud,  distinctly  vesicular 
respiration  ;  both  inspiration  and  expiration  being  augmented  in 
duration  and  loudness,  but  retaining  their  relative  length. 

Puerile  breathing  is  not  in  itself  a  sign  of  any  disease.  It  in- 
dicates rather  greater  activity  and  energy  of  the  part  over  which 
it  is  heard,  which  activity  makes  up  for  the  deficient  action  of 
other  parts.  In  this  manner  effusions  compressing  one  lung,  one- 
sided deposits,  or  obstruction  of  the  bronchial  tubes  by  secretions, 
necessitate  a  supplementary  respiration  in  the  healthy  portion  of 
the  same  lung,  or  in  the  other. 

A  diminution  of  the  vesicular  murmur,  or  feeble  respiration, 
consists  in  a  lessening  of  the  whole  sound  without  change  in  its 
character.  But  the  relation  of  inspiration  to  expiration  does  not 
remain  the  same  as  in  health.  In  the  large  majority  of  instances 
the  inspiration  suffers  most,  and  the  expiration  does  not  dimin- 
ish in  proportion  :  a  circumstance  explained  by  reference  to  the 
states  which  occasion  the  diminished  vesicular  murmur.  These 
are  varied ;  but  their  causes  may  be  reduced  to  four. 

18 


274 


MEDICAT.    DIAGNOSIS. 


1st.  Any  cause  Mliieli  obsti'iu'ts  the  passag-e  of  air  antl  prevents 
it  from  fiilly  rcaeliing  the  piihiionary  tissue.  Foreign  bcidies 
lodged  in  the  trachea  or  bronchi ;  affections  of  the  larynx  ;  con- 
siderable thickening  of  the  mucous  membrane  of  a  bronchial 
tube ;  its  compression,  or  the  accumulation  in  it  of  secretions,  or 
its  contraction  by  a  spasm, — all  diminish  the  quantity  of  the  air 
and  the  force  with  which  it  reaches  the  vesicles,  and  hence  reduce 
the  strength  of  the  murmur. 

2d.  Deiicient  respiratory  action.  This  may  arise  either  from 
general  debility ;  or  from  impairment  of  the  nervous  force,  as  in 
paralysis ;  or  from  local  pain,  as  in  pleurisy  or  in  pleurodynia. 

3d.  Causes  which  interfere  mechanically  with  the  free  expan- 
sion of  the  air-cells.  Pleuritic  effusions,  by  compressing  the  lung- 
tissue,  will  of  course  diminish  the  vesicular  murmur ;  so,  too,  will 
morbid  growths,  or  malformation  of  the  chest.  Comparatively 
slight  deposits  in  the  pulmonary  tissue  of  tubercle  or  of  lymph 
obliterate  some  air-cells,  and  prevent  others  from  unfolding,  and, 

by  having  impaired  their  elas- 
ticity, diminish  their  sound.  The 
same  loss  of  elasticity  happens  in 
emphysema :  the  overdistended 
cells  cannot  expand  much  more, 
they  are  rigid  and  more  or  less 
fixed ;  the  vesicular  murmur  is 
therefore  feeble. 

4th.  The  respiratory  murmur 
may  be  imperfectly  transmitted 
to  the  ear,  owing  to  intervening 
fluids  or  solids.  To  this  cate- 
o^orv  belono;s  the  enfeebled  mur- 
mur  so  constantly  met  with  in 
fat  persons. 

As  so  many  conditions  occa- 
sion a  feeble  respiratory  murmur,  it  is  only  by  association  with 
other  phenomena  that  it  acquires  much  importance.  Taking  the 
diseases  in  which  the  sound  is  most  frequently  found,  it  may  be 
stated  that  if  a  feeble  murmur  be  combined  with  dulness  on  per- 
cussion, it  signifies  a  tubercular  deposit,  or  a  pleuritic  effusion :  the 
former,  if  at  the  upper,  the  latter,  if  at  the  lower  part  of  the  lung. 


Diagram  illustrative  of  tlip  main  forms  of 
feeble  respiration.  <(,  from  distention  of  the 
cells  in  vesicular  emphysema ;  6,  from  deposits 
in  tlie  i)ulmonary  texture  ;  c,  from  a  solid  body 
(rf)  lodged  in  a  bronchial  tube,  which  lias  led  to 
])artial  or,  in  some  spots,  to  complete  collapse 
of  the  air-vesicles. 


DISEASES    OF   THE    LUNGS.  275 

If  it  be  connected  with  increased  clearness  on  percussion,  disten- 
tion of  the  air-cells  is  its  cause.  A  vesicular  murmur,  feeble 
throughout  both  lungs,  with  the  percussion  sound  unaltered,  arises 
from  general  debility,  or  from  obstruction  of  the  upper  air- 
passages.  Where  the  feebleness  of  the  murmur  is  found  to 
change  from  place  to  place,  it  is  dependent  upon  a  loose  foreign 
body  which  is  shifting  its  position  in  the  bronchial  tubes.  Joined 
to  unwillingness  to  expand  the  lung,  on  account  of  the  pain 
thereby  brought  on,  feeble  respiration  denotes  pleurodynia  or 
beginning  pleurisy. 

An  absence  of  the  vesicular  murmur  is  produced  by  the  same 
causes,  carried  a  step  further,  which  occasion  feeble  respiration. 
Complete  obstruction  of  the  tubes  by  foreign  bodies,  extensive 
deposits  in  the  pulmonary  tissue,  or  its  compression  by  large 
pleuritic  effusions,  arrest  the  vesicular  murmur.  But,  practically 
speaking,  there  is  only  one  complaint  in  which  we  are  apt  to  find 
it  entirely  wanting,  and  that  is  when,  associated  with  flatness  on 
percussion,  the  presence  of  a  large  collection  of  fluid  in  the  pleura 
is  attested.  Extensive  deposits  in  the  lung-tissue,  tubercular  or 
lymphous,  also  suppress  the  sound  of  the  air-cells ;  but  they  do 
not  suppress  all  sound.  The  noise  of  the  tubes,  the  bronchial 
respiration,  then  takes  the  place  of  the  vesicular  murmur,  and 
denotes  the  perfect  consolidation  of  the  pulmonary  tissue. 

Rhythm. — The  inspiration  and  the  expiration  may  be  altered  as 
regards  their  rhythm.  The  inspiration  may  be  broken  up  into 
little  puffs, — jerking  respiration ;  or  both  inspiration  and  expira- 
tion may  be  lengthened  or  shortened.  But  neither  lengthening 
nor  shortening  of  the  inspiratory  murmur  has  a  distinct  clinical 
value;  and  jerking  inspiration,  met  with  as  it  is  in  spasmodic 
affections,  in  hysteria,  in  pleurodynia,  and  in  tubercular  infiltra- 
tions, is  present  under  too  many  different  circumstances  to  have 
by  itself  much  diagnostic  significance.  But  if  limited  to  the 
apex,  it  may  serve  to  excite,  or  aid  in  corroborating,  a  suspicion 
of  tubercular  deposit.  One  modification  of  the  rhythm  is,  how- 
ever, of  decided  importance, — a  marked  increase  in  the  duration 
of  the  expiratory  murmur  while  the  patient  is  breathing  quietly. 

Prolonged  expiration  denotes  that  the  air  has  difficulty  in  get- 
ting out  of  the  lung.  It  is  detained  in  consequence  either  of  loss 
of  elasticity  of  the  cells,  or  of  an   obstruction  in  the  bronchi. 


276  MEDICAL    DIAGNOSIS. 

The  former  state  may  l^e  occasioned  bv  overdistention  of  the 
air-vesicles,  as  in  om[)hyscnia,  or  by  deposits  which  impair  their 
contractile  power.  In  the  first  case,  the  prolonged  expiration  is 
associated  with  angmented  clearness  on  percussion  ;  in  the  second, 
with  impaired  clearness.  Where  tlie  prolonocd  ex])iration  is  met 
with  at  the  apex  of  the  lung,  in  connection  with  dulncss,  it  is  for 
the  most  part  caused  by  a  tubercular  deposit. 

But  a  prolonged  expiration  from  tubercular  or  from  any  other 
kind  of  infiltration  is  not  simply  the  pure,  prolonged  expiration  of 
deficient  elasticity  of  the  air-cells.  It  is  something  more.  The 
solid  material  conducts  a  portion  of  the  sound  of  the  bronchial 
tubes  to  the  ear;  and  bronchial  breathing  is  nearly  always  best 
and  earliest  perceived  in  expiration.  Thus,  a  prolonged  expira- 
tion, when  joined  to  dulncss  on  percussion  and  to  an  inspiration 
still  vesicular,  is  a  sound  partly  vesicular,  partly  bronchial,  and 
may  be  interpreted  as  consolidation  of  the  lung-tissue ;  consolida- 
tion not  sufficient  to  have  obliterated  all  the  air-cells,  but  sufficient 
to  have  obliterated  some,  and  to  have  imjjaired  the  contractile 
power  of  others. 

The  obstacle  to  the  exit  of  the  air  may  reside  ^^'holly  in  the 
bronchial  tubes.  Such  is  the  source  of  the  prolonged  expiration 
when  the  mucous  membrane  of  the  bronchi  is  swollen.  Not 
only  does  this  condition  cause  the  air  to  be  retained  longer  in  the 
air-cells,  but  the  resistance  to  the  exit  of  the  column  of  air 
brings  out  more  of  the  bronchial  sound.  On  the  whole,  then, 
an  accurate  study  of  the  expiration  is  of  decided  value ;  and 
it  is  of  great  importance  to  impress  on  young  auscultators  the 
advantage  of  inquiring  into  the  expiration  separately  from  the 
inspiration. 

Character. — A  distinctive  character  of  the  vesicular  murmur  is 
its  softness.  From  the  moment  it  loses  this,  it  begins  to  jiass  into 
the  bronchial  sound.  Resj^iration  which  is  wanting  in  softness 
is  termed  harsh  respiration,  or,  to  modify  slightly  a  terra  intro- 
duced by  Flint,  resiculo-bronchial.  Harsh  breathing  is,  in  truth, 
a  union  of  the  vesicular  and  bronchial  sounds ;  it  is  a  vesicular 
sound  mixed  with  some  of  the  qualities  of  a  bronchial  sound, — a 
rougli  inspiration  devoid  of  all  the  softness  of  the  normal  respi- 
ratory murmur,  with  a  prolonged,  somewhat  blowing  expiration. 
Any  affection  which,  without  destroying  the  murmur  of  the  vesi- 


DISEASES    OF   THE    LUNGS.  277 

cles,  causes  the  sound  in  the  bronchial  tubes  to  be  produced  witli 
greater  intensity,  or  to  be  better  transmitted,  will  occasion  harsh 
breathing.  Thus,  it  exists  when  the  bronchial  membrane  is 
swollen,  as  in  bronchitis,  and  still  more  frequently  in  diseases 
Avhich  are  attended  with  compression  of  the  lung -tissue,  or  with 
partial  condensation,  such  as  some  stages  of  the  forms  of  i)hthisis 
or  of  pneumonia.  Being  a  transition  murmur  to  bronchial,  harsh 
respiration  shares  the  properties  of  the  latter  in  having  its  expira- 
tion more  developed  than  its  inspiration.  It  is  true,  the  inspira- 
tion alone  may  be  harsh,  and  the  expiration  not  be  much  changed  ; 
but  this  is  uncommon. 

Harsh  respiration  may  be  confounded  with  puerile  respiration, 
with  sonorous  rales,  and  with  bronchial  breathing.  From  the  first 
it  varies  by  its  higher  pitch,  its  roughness,  its  more  distinct  and 
blowing  expiration ;  from  sonorous  rales,  with  which,  however,  it 
often  coexists,  by  the  absence  of  all  vibrating  or  musical  character. 
From  bronchial  respiration  harsh  respiration  differs  merely  by 
degrees :  it  is  mixed  with  more  of  the  vesicular  sound,  is  less 
blowing  in  inspiration,  and,  when  produced  by  condensation,  is 
not  associated,  owing  to  the  smaller  amount  of  deposit  giving 
rise  to  it,  witli  so  much  dulness  on  percussion. 

Bronchial  Respiration. — Purely  bronchial  respiration  may 
exhibit  the  same  modifications  as  the  vesicular  murmur  in  respect 
to  rhythm  and  intensity.  But  neither  its  rhythm  nor  its  intensity 
is  of  significance ;  its  character  is.  To  hear  well-defined  bronchial 
respiration  is,  in  the  majority  of  cases,  to  meet  with  complete 
consolidation  of  the  pulmonary  tissue.  It  is  thus  that  in  extensive 
infiltrations  and  in  hepatization  of  the  lung  we  find  the  bronchial 
or  blowing  breathing  so  marked ;  particularly  so  in  the  latter 
morbid  state,  for  the  most  distinctly  blowing  or  tubular  respiration 
is  heard  in  pneumonia. 

The  bronchial  breathing  encountered  in  disease  resembles  more 
that  heard  in  health  over  the  larynx  or  trachea,  than  that  heard 
over  the  larger  bronchial  tubes.  It  entirely  replaces  the  vesicular 
sound,  which  has  for  the  time  being  ceased  to  exist.  It  differs 
from  the  normal  vesicular  murmur  by  its  higher  pitch ;  by  its 
occurrence  equally  in  inspiration  and  in  expiration ;  by  its  blow- 
ing character,  especially  in  expiration ;  and  by  the  pause  between 
inspiration  and  expiration.     Harsh  respiration  resembles  it  most ; 


278  MEDICAL    DIAGNOSIS. 

but  tliis  or  vesieulo-broncliial  respiration  is,  as  already  stated,  a 
transition  from  vesicular  to  bronchial  breathing. 

Whether  bronchial  respiration  be  owing,  as  Laennec  taught,  to 
a  better  transmission  of  the  sound  of  the  tubes  throup-h  the  solid 
lung ;  or  whether  it  be  produced,  as  Skoda  declared,  by  conso- 
nance, is  not  of  much  consequence  for  diagnosis.  The  important 
practical  fact  connected  with  this  form  of  respiration  is,  that  it 
happens  when  the  pulmonary  tissue  is  condensed,  which,  in  the 
large  majority  of  cases,  takes  place  from  exudations  or  deposits; 
in  a  small  proportion  only,  from  compression  by  growths  or 
effusions. 

A  variety  of  bronchial  respiration,  at  least  so  far  as  the  quality 
of  the  sound  determines  the  point,  is  that  significant  sign,  cavern- 
ous respiration.  This  is  essentially  a  blowing  sound  ;  yet  it  is  not 
always  distinct  during  both  inspiration  and  expiration,  being  often 
only  perceptible  in  the  one,  and  mixed  in  the  other  with  gurgling. 
The  question  whether  it  can  always  be  distinguished  from  bron- 
chial breathing  has  given  rise  to  much  dispute.  That  cavities 
may  exist  without  cavernous  respiration  being  perceived,  or,  on  the 
other  hand,  that,  owing  to  peculiar  physical  conditions,  cavernous 
respiration  may  have  been  heard  where  no  cavities  Avere  present, 
cannot  be  denied.  But  that  a  sound  is  met  with  which  is  less 
diffused,  much  more  hollow,  and,  above  all,  of  much  lower  pitch 
than  ordinary  bronchial  respiration  ;  that  connected  with  it  other 
signs  of  a  cavity  are  found ;  and  that,  under  such  circumstances, 
a  post-mortem  examination  proves  an  excavation  to  have  existed 
at  the  spot  where  during  life  the  sound  was  detected, — are  facts 
wliicli  equally  cannot  be  denied.  The  peculiar  sound  occurs,  and 
may  be  discerned  by  the  ear ;  and  no  theory,  ho\\'ever  cautious  it 
may  make  us  in  our  conclusions,  can  put  aside  the  evidence  of 
the  senses. 

Cavernous  respiration  is,  then,  a  blowing  sound  of  low  pitch, 
circumscribed,  alternating  with  gurgling,  and  deriving  its  chief 
character  from  the  cavity  in  which  it  is  formed.  Hollow  spaces 
of  any  kind — from  abscesses,  from  bronchial  dilatation,  from 
breaking-down  cheesy  degeneration,  from  softening  tubercle — ^give 
rise  to  it.  How  it  is  to  be  distinguished  from  bronchial  respira- 
tion has  already  been  indicated.  A  student  learns  this  sooner 
than  he  does  to  discriminate  between  cavernous  breathing  and  the 


DISEASES    OF    THE   LUNGS.  279 

vesicular  murmur ;  the  best  proof"  that  the  ear  recognizes  a  differ- 
ence between  bronchial  and  cavernous  respiration,  since  the  latter, 
as  a  sound  of  lower  pitch,  is  more  like  the  vesicular  murmur.  It 
is  only  necessary  to  recall,  with  reference  to  the  distinction  from 
the  sound  of  the  air-cells,  that  this  murmur  is  devoid  of  all 
blowing  quality. 

Amphorio  respiration  is  a  blowing  respiration  engendered  in  a 
large  cavity  with  firm  walls.  Its  peculiar  character  is  owing  to 
an  echo  from  the  walls  of  the  cavity.  It  may  be  humming  and 
of  low  pitch,  or  decidedly  ringing  and  metallic.  An  imitation  of 
the  sound,  though  only  an  imperfect  one,  is  effected  by  blowing 
into  an  empty  jar. 

Amphoric  or  metallic  respiration  is  always  indicative  of  a  large 
cavity ;  the  sound  is  rarely  met  with  in  phthisis ;  much  oftener  is 
it  heard  over  the  cavity  which  is  formed  between  the  layers  of  the 
pleura,  by  the  entrance  of  air. 

Another  variety  of  breathing  connected  with  a  cavity  is  the 
so-called  metamorphosing  breath  sound,  to  which  Seitz  has  called 
attention.  It  occurs  only  in  inspiration,  and  consists  of  a  very 
harsh  sound,  which  lasts  for  about  one- third  of  the  period  of  in- 
spiration, when  it  is  continued  as  blowing  respiration,  attended 
with  metallic  echo  or  ordinary  rales.  The  cause  of  the  phe- 
nomenon is  the  air  having  to  enter  through  a  narrow  opening  to 
reach  the  cavity.  Flint  regards  this  sign  as  a  variety  of  what 
he  calls  broncho-cavernous  respiration.  The  sound  of  expiration 
in  broncho-cavernous  breathing  is  bronchial,  high  in  jjitch,  and 
indicates  a  cavity  situated  near  a  portion  of  consolidated  lung. 
In  vesiculo-cavernous  respiration  the  cavity  is  surrounded  by  com- 
paratively intact  pulmonary  tissue,  and  this  gives  an  admixture 
of  vesicular  sound.* 

New,  or  Adventitious  Sounds. — These  consist  of  sounds 
which  have  no  analogue  in  the  healthy  state,  and  which  are  not, 
therefore,  modifications  of  the  normal  respiration.  Of  this  kind 
are  the  rales ;  crackling  ;  the  friction  sound. 

Nearly  all  rales,  or  rhonchi,  are  sounds  which  are  generated  in 
the  air-tubes  by  the  passage  of  air  through  them  when  contracted 
or  when  containing  fluid.     In  the  first  case  are  occasioned  dry,  in 

*  Lectures  on  Physical  Exploration  of  the  Lungs,  1882. 


280 


MEDICAL    DJAGNOSIS. 


the  second,  moist  rales.  Rales  may  occur  in  inspiration  or  in 
expiration,  or  during  both  acts.  Tliev  may  obscure  or  entirely 
take  the  place  of  the  natural  murmurs.  They  may  have  their 
seat  in  the  upper  air-tubes,  or  in  any  division  of  the  bronchi. 
When  in  tlie  laryux  or  in  the  trachea,  they  are  called  tracheal  rales  ; 
of  these  the  death-rattle  is  an  exanij)lc.  When  in  the  bronchial 
tubes,  they  are  designated  bronchial  rales ;  and,  as  this  is  their 

Fig.  22. 


Large 
bubbling. 


Small 
bubbling. 


Sonorous. 


Diagr.im  illustrative  of  rales.  The  narrowing  in  one  division  of  the  tube  gives  rise  to 
dry,  the  fluid  in  the  other  to  moist  rales.  The  rales  at  the  termiualion  of  the  tube  and 
in  the  air-vesicles  are  the  crepitant  or  vesicular  rales. 

most  frequent  situation,  the  term  rale  means  a  l^roncliial    rale 
unless  the  location  be  specially  indicated. 

Dry  rales  are,  for  the  most  part,  produced  by  the  vibration  of 
thick  fluids  which  the  air  cannot  break  up,  and  which  temporarily 
narrow  the  calibre  of  the  tube.  When  this  narrowing  exists  in 
the  smaller  bronchial  tube,  the  sound  which  results  is  high-pitched, 
— sibilant;  Avhen  in  the  larger,  unless  the  calibre  be  much  al- 
tered, it  is  low-pitched,  more  musical, — sonorous.  A  similar  dif- 
ference is  observed  with  reference  to  the  moist  or  buljbling  sounds. 
When  the  fluid  is  thin,  whether  it  be  mucus,  blood,  or  serum,  and 


DISEASES    OF    THE    LUNGS.  281 

breaks  up  into  large  bubbles,  large  bubbling  sounds  are  occasioned ; 
when  it  separates  into  small  bubbles,  small  bubbling  sounds  are 
the  consequence.  The  latter,  for  obvious  reasons,  generally  take 
place  in  the  smaller  tubes. 

Neither  dry  nor  moist  rales  are  persistent,  but  vary  in  intensity, 
or  shift  their  position,  as  the  air  drives  the  liquid  which  gives  rise 
to  them  before  it.  Dry  rales  are  particularly  prone  to  be  dislodged 
by  coughing.  When  they  are  uninfluenced  by  the  act  of  breathing 
or  of  coughing,  they  do  not  depend  upon  the  presence  of  secretions, 
but  upon  a  narrowing  of  the  air-tubes  from  the  pressure  of  sur- 
rounding tumors  or  from  a  fold  of  thickened  mucous  membrane, 
or  by  a  spasm. 

It  has  just  been  stated  that  rales  are,  for  the  most  part,  pro- 
duced in  the  bronchi  by  the  passage  of  air  through  fluids  there 
contained.  This  is  their  most  frequent  seat ;  but  they  are  not 
limited  to  the  tubes.  Similar  conditions  may  give  rise  to  rales  in 
other  places.  We  find  liquids  in  cavities  breaking  up  into  large, 
sharply-defined,  bubbling  rales,  the  so-termed  cavernous  rale, — 
gurgling ;  or  having  in  cavities  of  considerable  size  a  ringing 
metalllG  character ;  and  again,  the  presence  of  fluid  in  the  air-cells 
occasions  a  minute  rale, — the  crepitant. 

This  vesicular  rale,  or  crepitation,  is  a  very  fine  sound,  or  rather 
a  series  of  very  fine  uniform  sounds,  occurring  in  puffs,  and  lim- 
ited to  inspiration.  It  resembles  the  noise  occasioned  by  throwing 
salt  on  the  fire.  Its  name  indicates  its  seat.  It  is  caused  by  the 
agitation  of  fluid  in  the  air-cells  or  in  the  finest  extremities  of  the 
bronchial  tubes ;  or,  to  adopt  a  view  now  held  by  many,  by  the 
forcing  open  during  inspiration  of  the  air-cells  agglutinated  by 
the  exuded  lymph.  The  first  stage  of  acute  pneumonia  is  the 
state  in  which  this  rale  is  mostly  engendered. 

The  rales,  including  crackling,  may  be  thus  grouped  : 

f  Dry   or   vibrating  /  Low-pitched  (sonorous). 

I        sounds.  I  High-pitched  (sibikut). 

Bronchial  Rales.  -|   -,r  •  ^      i,  ^x.^■        r  r  i    iw       /  \ 

Moist  or  bubbhng   f  Large  bubbnng  (mucous). 

I        sounds.  I  Small  bubbling  (subcrepitant). 

Vesicular  Kales.  |  ^^^pitation. 
Cracklino;  ? 


Kale  of  Cavities. 


Hollow  bubbling,  or  gurgling. 
Metallic  rales. 


282  MEDICAL   DIAGNOSIS. 

Qrackling  is  a  sign  closely  connected  with  rales,  and,  though 
its  mechanism  is  undecided,  it  is  regarded  as  a  rale.  It  consists 
of  a  few  tine  and  readily-discerned  crafkling  sounds  which  happen 
generally  in  cases  of  pulmonary  tubercle,  and  of  N\hich,  therefore, 
they  are  considered  as  diagnostic. 

The  distinction  between  crackling  and  the  crepitant  rale  is  one 
most  puzzling  to  a  beginner.  Nor  is  there,  in  reality,  any  differ- 
ence, except  in  the  number  of  the  sounds.  Crackling  is  a  few 
fine  sounds  limited  to  inspiration,  and  heard  commonly  at  the 
apex  of  the  lung.  Crepitation  is  a  number  of  fine  sounds  limited 
to  inspiration,  but  more  diffused,  and  heard  generally  at  the  base 
of  the  lung.  The  sound  is  similar  because  the  conditions  giving 
rise  to  it  are  similar.  Both  depend  upon  tenacious  fluid  or  semi- 
fluid matter  in  the  ultimate  structure  of  the  lung :  in  the  one  case 
it  is  tubercle  or  cheesy  degeneration,  in  tlie  other  usually  the 
lymph  of  beginning  inflammation.  The  crackling  wdiicli  indi- 
cates softening,  as  of  tubercle, — called  by  some  authors  moist 
crackling,  by  others  clicking, — is  a  succession  of  sounds  like  small 
moist  rales,  only  less  liquid  than,  these,  because  breaking-uj)  tu- 
bercle is  not  very  fluid.  The  fine  or  dry  crackling  of  the  earlier 
stages  of  phthisis  corresponds,  then,  to  a  vesicular  rale ;  the 
coarser,  or  moist  crackling,  to  the  small  bubbling  sound.  When 
the  bubbles  become  larger  and  larger,  and  cavities  form,  and  the 
fluid  matter  in  them  is  agitated  by  the  ingress  and  egress  of  air, 
the  large,  bubbling,  ringing  rale  of  cavities,  or  gurgling,  is  oc- 
casioned. Dry  crackling,  moist  crackling,  and  gurgling  accord 
then  with  the  crepitant  rale,  small  bubbling,  and  large  bubbling 
sounds,  and  happen  in  the  progressive  stages  of  infiltration  and 
softening  of  deposits,  and  generally  in  those  of  a  tubercular  nature. 

Pleural  friction,  or  the  sound  due  to  the  rubbing  together  of 
roughened  pleural  surfaces,  consists  of  a  number  of  abrupt  super- 
ficial noises  heard  in  inspiration  and  expiration,  rarely  in  either 
alone.  Its  seat  is  not  usually  extended,  for  it  is,  as  a  rule,  only 
audible  over  portions  of  the  lower  part  of  one  side  of  the  chest. 
Sometimes  it  is  so  creaking  and  intense  as  to  be  distinctly  percep- 
tible to  the  hand  as  Avell  as  readily  recognizable  by  the  ear.  But 
it  may  be  so  much  like  crepitation  that  even  long  practice  in  aus- 
cultation will  not  enable  us  to  determine  at  once  whether  the  fine 
sounds  we  hear  are  the  friction  of  a  roughened  pleura,  or  the  vesic- 


DISEASES    OF   THE    LUNGS.  283 

ular  rales  of  an  inflamed  lung.  It  is  easy  to  lay  down  in  books  the 
distinguishing  mark  of  greater  superficiality ;  but  at  tlie  bedsld(i  the 
difficulty  remains  the  same,  and  is  removed  only  by  attention  to  the 
physical  signs  and  symptoms  accompanying  the  doubtful  sounds. 
Nor  is  it,  in  some  cases,  less  perplexing  to  discriminate  between 
fine  friction  sounds  and  fine  moist  rales.  By  the  sound  alone  it 
is  often  impossible ;  concomitant  phenomena  must  be  taken  into 
account.  A  friction  sound  is  mostly  confined  to  a  smaller  space, 
and  is  uninfluenced  by  cough ;  while  cough  changes  the  position 
and  the  distinctness  of  rales.  Yet  even  this  rule  is  not  absolute. 
A  fine  friction  sound  may  be  temporarily  increased  during  the 
deep  breathing  which  follows  the  act  of  coughing ;  on  the  other 
hand,  the  influence  which  cough  exerts  on  the  small  moist  rale  is 
not  so  great  as  on  the  larger  bubbling  sound.  As  for  the  more 
marked  character  of  moisture  which  a  rale  is  said  to  possess,  that 
only  aids  us  in  some  cases.  Where  the  secretions  are  viscid,  it 
would  require  a  sense  of  hearing  more  delicate  than  belongs  to 
the  majority  of  mankind  to  judge,  by  the  application  of  this  test, 
whether  the  sound  we  perceive  is  formed  in  the  lung  or  on  its 
covering.  As  the  result  of  investigations  undertaken  to  ascertain 
whether  there  is  any  positive  difference,  so  far  as  the  ear  can 
detect,  between  some  of  the  finer  kinds  of  friction  and  fine  moist 
rales,  I  have  come  to  the  conclusion  that  frequently  little  or  none 
exists ;  and  still  less  is  there  between  crackling  and  the  crackling- 
variety  of  friction  sound,  or  between  this  and  the  vesicular  rale. 
The  features  most  at  variance  are  :  that  the  friction  phenomena 
are  not  strictly  limited  to  inspiration  as  are  the  vesicular  rales,  are 
not  seldom  coarser  in  expiration  than  in  inspiration ;  that  they  are 
less  uniform  ;  and  that  their  seat  is  more  circumscribed.  Their 
production  nearer  to  the  ear  may  assist  us,  but  does  not  always. 
The  reason  why  some  of  the  finer  friction  sounds  resemble  so 
closely  fine  moist  rales  or  crepitation  is  apparent  when  we  reflect 
that  the  irregularities  in  the  pleura  may  be  slight,  and  be  sur- 
rounded by  fluid  which  keeps  them  moistened.  Bruen  has  called 
attention  to  the  value  of  making  the  chest- walls  immovable.* 
When  tlie  chest  is  fixed,  especially  at  the  lower  two-thirds,  bv  the 
hand  of  an  assistant,  and  the  ear  or  the  stethoscope  is  applied  over 

*  Physical  Diagnosis. 


284  MEDICAL   DIAGNOSIS. 

tlie  doubtful  sounds,  they  w'ill  be  found  to  have  disappeared  if  of 
pkniral  origin,  but  to  be  still  discernible  if  rales. 

The  creaiving  or  grating  varieties  of  friction  are  nuich  easier  of 
recognition  than  the  finer  forms.  Their  discrimination  from  rales 
is  readily  eifected  by  noticing  the  rubbing  and  harsh  character  they 
possess. 

Auscultation  of  the  Voice. 

Attention  to  the  voice,  as  heard  over  the  chest,  is  by  some 
regarded  as  very  important  in  examinations  of  the  lungs.  Yet 
the  information  derived  from  a  study  of  the  thoracic  voice  is  very 
slight  unless  confirmed  by  other  physical  signs. 

When  the  ear  is  applied  to  the  thorax  of  a  healthy  person  who 
is  speaking,  a  confused  hum  is  perceived,  most  distinct  in  adults 
who  are  possessors  of  a  deep  voice,  and  tremulous  in  the  aged. 
Now,  the  normal  vocal  resonance,  for  by  that  name  the  ill-defined 
vibrations  are  called,  is  more  marked  on  the  right  than  on  the  lelt 
side,  and  corresponds  to  the  vesicular  murmur.  Over  the  bronchial 
tubes  a  more  concentrated  sound  strikes  the  ear.  This,  termed 
bronchophony,  accords  with  bronchial  respiration,  and,  when  de- 
tected over  the  lung,  denotes,  with  rare  exceptions  hereafter  to  be 
referred  to,  the  same  as  bronchial  respiration, — increased  density 
of  pulmonary  tissue  caused  by  pressure  or  by  deposit.  Any  nor- 
mal vocal  resonance  which  is  augmented  passes  by  degrees  into 
bronchophony,  and  has  a  meaning  similar  to  it. 

Of  the  sound  known  as  bronchophony  there  are  several  varie- 
ties:  the  simple  bronchophony  }ust  ex])\ained, — observed  in  pneu- 
monia, or  in  any  form  of  consolidation ;  the  hollow,  cavernous 
voice,  or  pectoriloquy  ;  and  the  bleating  variety,  or  segopliony. 
The  latter,  indicative  of  a  thin  layer  of  fluid  between  compressed 
lung  and  the  ear,  is  a  sign  generally  too  transitory  to  be  of  much 
diagnostic  value  ;  and  pectoriloquy,  if  by  this  be  iniderstood  what 
Laennec  meant, — complete  transmission  of  articulated  words, — is 
of  no  special  significance,  as  it  may  be  met  with  where  no  cavity 
exists.  But  if  the  term  be  applied  to  a  well-defined  chest-voice, 
of  hollow  character,  and  heard  as  such  over  a  comparatively 
limited  space,  pectoriloquy  is  a  distinct  physical  sign,  and  really 
deserves  the  name  of  cavernous  voice.  This  is  particularly  true 
of  ivhispenng  pectoriloquy.  Over  large  cavities  the  voice  is  pe- 
culiarly ringing    and    metallic.      The   conditions  which  produce 


DISEASES   OF   TflE   LUNGS.  285 

amphoric  or  metallic  voice  are  the  same  as  those  which  occasion 
any  of  the  amphoric  or  metallic  phenomena.  J5e  the  respiration 
metallic,  be  the  voice  metallic,  be  the  rales  metallic,  they  are  all 
caused  by  a  cavity  large  enough  and  with  walls  firm  enough  to 
reflect,  to  echo  the  sound. 

Bronchophony  and  amj^horic  voice  are  instances  of  increase  and 
change  of  character  of  the  normal  vocal  resonance.  A  diminished 
vocal  resonance  occurs  when  the  lung  is  compressed  by  air  or  fluid, 
as  in  pleuritic  effusions,  or  in  pneumothorax  ;  or  when  it  is  greatly 
distended  with  air,  as  in  extreme  cases  of  emphysema.  Clinically 
speaking,  the  sign  is  oftenest  encountered  in  pleuritic  effusions. 

The  vibrations  of  the  voice  may  he  felt  as  well  as  heard.  The 
vibration  detected  by  placing  the  hand  over  the  thorax  when  the 
patient  speaks,  the  vocal  fremitus,  is,  like  the  voice,  increased  by 
all  consolidation  of  pulmonary  tissue,  and  diminished  by  fluid  or 
air  in  the  pleura.  Its  relations  to  the  voice  are,  however,  not 
uniform  ;  and  sometimes  with  increased  density  of  the  lung-tissue 
there  is  no  increased  fremitus,  although  there  is  increased  chest- 
voice. In  women  the  sign  is  valueless ;  indeed,  its  main  impor- 
tance is  derived  from  its  absence  in  cases  of  pleuritic  effusions. 
Just  as  the  voice,  it  is  most  marked  on  the  right  side. 

Rales,  when  extensive,  sometimes  cause  a  vibration  to  be  trans- 
mitted to  the  chest-walls,  as  do  the  fluids  in  cavities.  The  former 
phenomenon  is  called  the  bronchial  fremitus,  the  latter  the  cavern- 
ous fremitus.  A  friction  sound  that  may  be  felt  is  designated  as 
the  pleurcd  f  remit  us. 

The  Combination  of  the  Physical  Signs,  and  the  Examination 
of  Patients  affected  with  Disease  of  the  Lungs, 

In  the  preceding  pages  isolated  physical  signs  have  been  dis- 
cussed. But  if  in  the  investigation  of  disease  we  were  to  trust 
solely  to  isolated  signs,  our  conclusions  would  be  incomplete  and 
unsatisfactory.  All  the  methods  of  physical  exploration  must  be 
employed,  the  results  obtained  compared  with  one  another,  and 
the  attending  symptoms  carefully  inquired  into  and  brought  into 
connection  with  the  physical  signs,  before  a  diagnosis  is  made. 

A  patient  presents  himself  for  examination.  After  having 
obtained  the  history  of  the  case,  it  is  well  to  look  at  his  general 
appearance ;  to  scan  the  expression  of  his  countenance ;  to  feel  the 


286 


^[EDICAL   DIAGNOSIS. 


skill  and  the  pulse  ;  to  inquire  into  the  nature  of  the  cough  and  of 
the  expectoration  ;  and  to  determine  the  existence  of  pain.  The 
character  and  frequency  of  the  breathing  are  noted.  Next  we 
proceed  to  a  physical  exploration.  The  chest  is  watched ;  its 
movements,  its  size,  are  inspected, — if  necessary,  measured.  Per- 
cussion is  employed,  then  auscultation. 

The  manner  of  investigating  by  these  methods  has  been  detailed ; 
it  need  not  here  be  repeated.  But  what  may  be  repeated  is,  that 
there  are  two  lungs ;  that  it  is  incumbent  always  to  explore  both, 
and,  as  we  proceed,  to  compare  the  action  of  one  with  that  of  the 
other.  Nor,  even  when  the  pulmonary  affection  has  been  made 
out,  ought  the  examination  to  be  stopped.  The  state  of  other 
organs  and  of  the  system  must  be  inquired  into,  so  as  not,  in 
the  pursuit  of  a  few  physical  signs  in  the  lung,  to  pass  by  accom- 
panying disorders  of  the  heart,  or  liver,  or  stomach  ;  so  as  not 
to  overlook  vital  conditions,  compared  with  which,  as  respects  the 
treatment,  the  physical  phenomena  often  sink  into  insignificance. 
There  are  acute  and  chronic  diseases  of  the  lung.  The  physical 
signs  of  both  may  be  the  same ;  but  the  general  symptoms  and 
the  constitutional  state  attending  them  are  not  always  identical. 
In  truth,  these  are  at  times,  in  the  same  malady,  so  different  as 
to  render  a  remedy  which  is  of  use  in  one  case,  nseless  or  worse 
than  useless  in  another. 

As  many  of  the  signs  elicited  by  the  various  methods  of  phys- 
ical diagnosis  depend  on  the  same  physical  conditions,  they  may 
be  studied  in  groups.     The  following  will  be  usually  found  to  be 

associated : 

Association  of  Physical  Signs. 

PfRCI'SSIOV         Al-SCULTATinM    of      AlTSCUI.TATlON      VOCAL  FREMITUS.  PHYSICAI.   CONDITION. 

jTj'.KLisbiu.N.         Kespiration.  or  Voice. 

Clear Vesicular  Normal  vocal        Unimpaired.      Lung-tissue  healthy  or  nearly 

murmur  or  resonance.  so ;  at  any  rate,  no  increased 

its  modifi-  density  of   lung-tissue   from 

cation.  '  deposit  or  from  pressure, 

r  Bronchial,  Bronchophony.    Increased.  Solidification      of      pulmonary 

I      or  harsh  structure. 

Dull ■i      respiration. 

I  Absent  respi-         Absent  voice.       Diminished         Effusion  into  pleural  sac. 
I     ration.  or  absent. 

Tympanitic Cavernous  or        Uncertain;  Uncertain;  Increased  quantity  of  air  with- 

feeble,  accord-      cavernous  or        mostly  di-  in  the  chest,  or  air  confined 

ing  to  cause.         diminished.  minished.  in   particular  points ;   states 

commonly  due  to  a  cavity, 
or  to  overdistention  of  the 
air-cells. 


DISEASES    OF    THE    LUJS'GS.  287 

Amphoric     or  Amphoric  or  Amphoric  or  Mostly  diniin-  Large  cavity  witli  elastic  walls 

metallic metallic.  metallic.  islied. 

CracUed-metal  Caveruous  Cavernous  Uncertain.  Generally   a   cavity    commiiiii- 

soiind respiration.  voice.  eating  with  a  hronchial  tulje. 

In  adults  these  phenomena  are  commonly  combined.  In  chil- 
dren, however,  their  connection  is  not  so  constant  nor  so  apparent. 
Owing  to  the  extreme  elasticity  of  the  thoracic  walls  and  the 
naturally  clearer  sound  of  the  lungs,  the  relations  of  percussion 
to  auscultation  are  not  the  same  as  in  the  adult.  Dulness,  even 
where  the  condition  exists  for  its  production,  is  rarely  as  marked ; 
nor  is  comparison  between  the  two  sides  of  the  chest  as  valua- 
ble, since  most  of  the  acute  pulmonary  affections  of  childhood 
are  more  often  double  than  those  of  adolescence.  Again,  the 
diagnosis  of  the  diseases  of  the  lung  in  children  requires  some 
knowledge  of  the  disorders  to  which  they  are  peculiarly  liable, 
and,  above  all,  great  care  and  patience. 

Among  some  of  the  peculiarities  of  the  respiratory  function, 
before  the  age  of  puberty,  may  be  mentioned  the  greater  frequency 
of  breathing.  Infants  between  two  months  and  two  years  breathe 
irregularly,  and  about  thirty-five  times  in  a  minute.  Between 
the  ages  of  two  and  six  years  the  average  number  of  resj)irations 
in  the  same  space  of  time  is  twenty-three.  The  breathing  is  also 
of  a  different  type  from  that  of  the  adult ;  it  is  abdominal,  and 
can  be  more  readily  counted  by  noting  the  rising  and  sinking  of 
the  abdomen  than  by  watching  the  slight  movements  of  the  chest. 

Of  the  methods  of  physical  exploration,  auscultation  is  in  chil- 
dren the  most  applicable.  It  is  far  more  so  than  percussion,  and 
is  to  be  practised  first,  since  percussion  causes  the  child  to  cry. 
The  voice  as  weii  as  the  breathing  may  be  advantageously  listened 
to ;  and  although  the  fretful  patient  will  not  or  cannot  speak,  it 
can  and  does  cry.  From  the  cry,  when  studied  with  the  ear 
applied  to  the  thoracic  walls,  we  may  obtain  the  same  indications 
as  from  the  vocal  resonance.  The  back  of  the  lungs  should  be 
invariably  examined.  It  is  there  that  the  mischief  is  mostly 
seated.  Fortunately,  also,  this  investigation  does  not  occasion  the 
same  fear  or  struggling  on  the  part  of  the  little  sufferer :  hence  it 
is  better  not  to  place  the  ear  to  the  anterior  portion  of  the  chest 
until  the  posterior  has  been  listened  to.  The  position,  too,  in 
which  the  child  is  auscultated  should  vary  with  its  age.  Very 
young  children  may  be  examined  either  in  a  lying  or  sitting  pes- 


288 


MEDICAL    DIAGNOSIS. 


ture  on  the  lap  of  their  nurses,  or  may  be  held  in  the  arms  of  an 
attendant,  Avho  is  direeted  to  present  the  different  parts  of  the 
thorax  successively  to  the  ear  of  the  physician. 

Before  proceeding  to  the  discussion  of  the  symptoms  of  pul- 
monary diseases  and  of  the  diseases  themselves,  let  us  group  the 
latter  according  to  their  anatomical  seat. 

Diseases  of  the  Lungs  and  their  Coverings. 


r 


Bronchial   Tubes... 


Inlltuuniation,  or 
Bi'onchitis ; 


I  Acute  ...  i 


Of  lurge-sized  tubes. 
Of  capillary  tubes. 


I'  Ordinary  cbronic 

,-,,        .  catarrlial  form. 

Chronic.  J    ^      . ,  ,  ,  .  . 

Putrid  bronchitis. 

L  Fibrinous  bronchitis 


Dilatation  ; 

Nari'owing  ; 

Diseases  of  bronchial  glands  ; 

Spasm  of  muscular  fibres,  or  asthma. 

l'  Congestion ; 
Hemorrhages ; 
Apoplexy ; 
(Edema ; 
Collapse ; 
Hypertrophy ; 

Inflammation,  or  pneumonia,  in  varied  forms; 
Induration  ; 

Lung-Tissue \   Phthisis  of  diflerent  kinds  ; 

Abscess ; 
Cirrhosis ; 
Gangrene ; 
Emphysema ; 

Tubercle,  chronic  and  acute  ; 
Cancer ; 

Deposits,  such  as  syphilitic,  melanic,  etc. ; 
[  Parasites. 

Inflammation,  or  pleurisy ; 

Empyema ; 

Hydrothorax  ; 
1  Ha;mothorax ; 
I  Tuberculosis ; 
I  Malignant  growths. 

Pneumothorax ; 

Perforations  and  fistulous  openings. 

Pleurodynia ; 

Walls  of  Chest -|  Intercostal  neuralgia  ; 

Abscesses,  etc. 


Pleura. 


Pleura  and  Lun 


-•■  { 


DISEASES   OF   THE   LUNGS.  289 


The  Principal  Symptoms  of  Diseases  of  the  Lungs. 

After  having  described  the  physical  signs  of  pulmonary  affec- 
tions, it  is  necessary  to  inquire  into  the  more  prominent  symptoms 
they  occasion.  At  the  same  time,  several  of  the  disorders  which 
are  mainly  recognized  by  these  symptoms,  and  the  physical  signs 
of  which  are  comparatively  unimportant,  will  be  dwelt  upon. 

Yet  of  the  symptoms  about  to  be  mentioned,  not  one  belongs 
exclusively  to  pulmonary  diseases.  We  have  met  with  some  of 
them  in  studying  laryngeal  complaints ;  we  shall  meet  with  them 
arain  in  examinino:;  the  affections  of  the  heart.  And  in  investi- 
gating  them  here  we  shall  not  vieAV  them  simply  with  reference  to 
morbid  states  of  the  lungs,  but  shall  indicate  their  general  relations 
to  diseased  conditions,  even  at  the  risk  of  discussing  what  might 
in  part  be  more  appropriately  discussed  elsewhere. 

The  symptoms  which  it  is  proposed  more  specially  to  sift  are 
dyspna?a,  cough,  and  hsemoptysis. 

Dyspnoea. — Dyspnoea  means  difficulty  of  breathing.  It  is 
accompanied  mostly  by  a  sense  of  uneasiness  and  suffocation, 
and  by  increased  frequency  of  the  respiratory  act.  But,  strictly 
speaking,  it  is  not  correct  to  apply  the  term  dyspnoea  to  mere 
increased  frequency  of  breathing,  for  accelerated  respiration  and 
difficult  respiration  do  not  of  necessity  go  hand  in  hand.  The 
breathing  may  be  slower  than  natural,  yet  laborious ;  it  may  be 
quick,  and  not  impeded.  Pneumonia  furnishes  often  an  example 
of  this. 

Dyspnoea  depends  upon  various  causes.  Feeble  persons  are 
sometimes  troubled  with  it  after  the  slightest  exertion.  It  may 
be  temporarily  produced  by  any  bodily  or  mental  excitement.  It 
is  observed  when  the  play  of  the  diaphragm  is  interfered  with, 
and  the  lung  cramped  in  its  expansion.  This  is  its  cause  in 
ascites,  in  abdominal  tumors,  and  in  pregnancy.  It  may  occur  in 
perverted  innervation,  as  in  hysteria,  or  in  connection  with  cere- 
bral affections,  from  a  want  of  power  in  the  respiratory  muscles, 
or  it  may  be  due  to  morbid  conditions  of  the  blood,  as  in  anaemia, 
scurvy,  uramia,  and  pyaemia.  It  is,  however,  most  frequently 
met  with  as  a  prominent  symptom  of  the  disorders  of  the  larynx 
and  trachea,  or  of  the  heart,  and  in  the  various  diseases  of  the 

19 


290  MEDICAL   DIAGNOSIS. 

lung  and  pleura,  whether  idiopathic  or  secondary.  Being  common 
to  so  maliv  morbid  states,  it  is  not  diagnostic  of  any. 

Dyspurt-a  is  usually  aggravated  by  position.  Wlien  the  patient 
lies  on  his  back,  the  respiration  becomes  more  difficult.  The  form 
of  dyspntva  in  which  the  sufferer  is  obliged  to  remain  in  the  erect 
posture  in  order  to  breathe,  is  termed  orthopnmi.  This  is  witnessed 
in  hydrothorax,  in  oedema  of  th(^  lung,  and  in  affections  of  the 
mitral  or  tricuspid  valves.  In  capillary  bronchitis  the  trouble  in 
respiring  is  very  great ;  so,  too,  is  it  in  pneumothorax,  in  emphy- 
sema, and  in  pleurisy,  if  the  lung  be  extensively  compressed. 

Dyspnoea  may  come  on  in  paroxysms,  and  constitute  the  only, 
or  certainly  the  main,  symptom  of  disease.  This  is  the  case  in 
asthma. 

AdhriKi. — .Isthma  consists  in  a  spasmodic  narrowing  of  the 
bronchial  tubes,  caused  by  a  contraction  of  their  circular  muscu- 
lar fibres.  Its  chief  symptom  is  great  distress  in  breathing,  oc- 
curring in  paroxysms,  and  attended  with  wheezing.  These  spasms 
may  be  preceded  by  a  feeling  of  suffocation,  or  they  may  come  on 
suddenly.  The  patient  wakes  up  out  of  his  sleep,  iinds  himself 
wheezing  and  with  a  fit  of  the  disease  fully  on  him.  He  con- 
tinues to  respire  with  great  difficulty,  sits  upright  in  bed,  or 
Avalks  about  the  I'oom  gasping  for  breath.  His  look  is  anxious, 
the  face  pale,  and  the  color  of  the  lips  shows  that  the  blood  is  not 
properly  aerated.  In  spite  of  the  struggle  to  get  air  into  the 
lungs,  the  chest  moves  but  little ;  and  when  the  ear  is  placed  on 
it,  no  vesicular  murmur  is  heard, — simply  the  same  loud  wheez- 
ing which  is  perceptible  to  the  by-standers ;  or  sonorous  and  sibi- 
lant rales  are  detected,  due  to  the  narrowing  of  the  bronchial  tubes, 
and  disappearing  with  the  spasm.  These  dry  rales  are  chiefly  ex- 
piratory, and  the  lungs  are  very  full  of  air,  and  displace,  by  sev- 
eral intercostal  spaces,  the  diaphragm  downwards.  At  the  end 
commonly  of  some  hours  the  fit  passes  off  with  coi)ious  expecto- 
ration, and  as  suddenly  as  it  came.  But  it  may  last  for  days, 
ameliorating  in  the  daytime,  exacerbating  at  night,  and  only 
ceasing  gradually. 

The  exciting  causes  of  these  bronchial  spasms  are  various.  In 
some  persons  there  is  no  apparent  reason  for  the  attack  ;  in  others 
it  is  brought  on  by  the  inhalation  of  irritating  fumes  or  of  dis- 
agreeable vapors.     In  some  it  is  preceded  by  digestive  disorder,  or 


DISEASES    OF    THE    LUNGS,  291 

by  bronchial  catarrh ;  in  others,  again,  an  interruption' to  the  free 
circulation  of  blood  in  the  lung,  or  a  disturbance  in  the  sexual 
oro-ans  or  in  the  urinary  secretions,  seems  to  occasion  it.  It  is 
not  unusual  to  find,  on  closely  questioning  patients,  that  for  some 
time  prior  to  the  asthmatic  paroxysm  they  have  passed  a  scanty, 
dark-colored  urine.  During  the  attacks  Leyden  *  found  in  the 
sputum  colorless,  pointed,  octahedral  crystals  soluble  in  warm 
water,  in  alkalies,  acetic  acid,  and  the  mineral  acids.  They  have 
been  thought  by  some  to  be  the  cause  of  the  attacks. 

Now,  whatever  be  the  exciting  agent  that  calls  the  bronchial 
spasm  into  existence,  the  symptoms  of  the  attack  of  asthma  are 
the  result  of  that  spasm.  Yet  asthma  is  not  often  a  pure  neurosis. 
The  seizure  itself  is  the  expression  of  perverted  nervous  action ; 
but  there  are  generally  permanent  conditions  present,  such  as  dis- 
ease of  the  brain  or  medulla,  of  the  heart,  or  of  the  lungs,  which 
act  as  constantly  predisposing  causes  to  these  seizures,  and  lead  to 
attacks  either  by  direct  irritation  of  the  pneumogastric  nerves  or 
through  the  medium  of  the  reflex  system.  Emphysema  especially 
is  a  fruitful  source  of  spasmodic  asthma. 

The  detection  of  the  causes  inducing  an  asthmatic  fit  may  be 
difficult ;  but  the  diagnosis  of  the  fit  itself  is  not  so.  No  disease 
of  the  lungs  or  bronchial  tubes  is  likely  to  be  mistaken  for  it, 
because  no  disease  of  either  gives  rise  to  the  same  symptoms. 
The  dyspnoea  of  pleurisy  or  bronchitis  is  not  paroxysmal,  nor  is 
it  attended  with  wheezing.  Some  of  the  affections  of  the  larynx 
and  trachea  bear  a  nearer  resemblance ;  yet  they,  too,  aimounce 
themselves  by  different  symptoms.  Asthma  may  be  distinguished 
from  croujj  by  the  entire  absence  of  fever,  and  by  its  lacking  the 
peculiar  hoarse  voice  and  cough  which  appertain  to  both  forms  of 
this  malady.  The  age  of  the  patient  is  also  very  different :  asthma 
is  as  rare  in  a  child  as  croup  is  in  an  adult.  (Edema  and  spasm 
of  the  glottis  differ  from  asthma  by  the  much  more  markedly 
paroxysmal  nature  of  the  difficulty  of  breathing,  by  the  shorter 
duration  of  the  seizures,  and  by  the  absence  of  the  loud  and  con- 
tinued wheezing.  The  sensations  of  the  sufferer,  further,  indicate 
correctly  the  seat  of  the  obstruction.  And  so  they  are  apt  to 
do  in  some  of  the  paralyses  of  the  vocal  apparatus,  where  noisy 

*  Virchow's  Archiv,  1872. 


292  MEDICAL   DIAGNOSIS. 

dyspnoea  happens,  and  is  aggravated  in  paroxysms.  Further,  we 
are  aided  here  by  the  aphonia,  by  the  inspiratory  character  of  the 
stridulous  breathing,  by  the  absence  of  chest  rales,  and  by  the 
obvious  lesion  seen  in  the  laryngeal  mirror.  A  large  goitre  pi'ess- 
ing  on  the  trachea  may  give  rise  to  dys[)na'a  and  to  a  noisy  sound 
in  breathing ;  but  the  cause  of  both  is  easily  traced  to  the  tumor 
in  the  neck. 

The  most  decejitive  condition  is  when  the  r/lands  of  the  neck 
enlarge  suddenly  and  press  on  the  trachea.  I  had,  some  time 
since,  a  young  man  under  my  care  for  acute  bronchitis.  He 
was  progressing  favorably,  when  one  day  he  presented  himself, 
breathing  with  great  difficulty,  and  each  respiration  attended 
with  a  noise  like  the  wheeze  of  asthma.  I  should  have  regarded 
him  as  having  been  attacked  with  asthma  had  I  not,  in  looking 
at  his  neck,  detected  the  group  of  enlarged  glands.  Such  cases 
are  extremely  rare,  and  belong  to  the  curiosities  of  medical  practice. 

Marked  dyspnoea  may  be  occasioned  by  the  pressure  of  an 
aneurismal  tumor,  or  by  an  organic  disease  of  the  heart.  But  it 
is  hardly  necessary  to  enter  here  into  a  detailed  description  of  the 
distinctive  character  of  either  of  these  forms  of  troubled  breathing. 
The  stridor  and  the  persistent  difficulty  of  respiration  in  the  first, 
aggravated  though  it  may  become  in  paroxysms,  and  the  constant 
want  of  breath  in  the  second,  are  not  likely  to  be  mistaken  for 
the  wheezing  and  the  paroxysmal  dyspnoea  of  asthma.  True 
asthmatic  seizures  may  both  produce  and  be  produced  by  a  dis- 
ease of  the  heart.  But  Avhat  is  called  ''cardiac  asthma"  is  not 
often  a  spasm  of  the  bronchial  tubes :  it  is  usually  only  a  tem- 
porary increase  of  the  dyspnoea,  dependent  upon  a  decided  ob- 
struction to  the  circulation  in  the  lungs,  and  not  accompanied 
by  wheezing. 

There  is  a  peculiar  form  of  difficulty  of  breathing  connected 
^vith  a  loss  of  poicer  in  the  diaphragm.  The  patient,  when  the 
disorder  is  fully  developed,  cannot  make  even  the  slightest  effi)rt 
without  his  being  seized  with  a  feeling  of  suffiication  and  his  res- 
piration being  greatly  accelerated.  He  cannot  take  a  long  breath, 
and  often  his  voice  is  much  enfeebled.  But  the  most  significant 
sign  of  the  paralysis  is,  that  during  inspiration  the  epigastrium 
and  the  hypochondria  are  depressed,  Avhile  the  chest  dilates ;  and 
the  converse  takes  place  during  expiration.     If  there  be  merely  a 


DISEASES   OF   THE   LUNGS.  293 

lessened  power  of  the  diaphragm,  these  phenomena  are  observed 
only  during  forced  breathing ;  a  paralysis  of  one-half  of  the 
muscle  occasions  them  on  one  side  alone.  Duchenne  adds  another 
important  diagnostic  test  of  a  paralyzed  state  of  the  diaphragm, 
— namely,  that  if  the  phrenic  nerve  be  galvanized,  the  dia- 
phragm acts  again  with  proper  strength,  and  during  inspiration 
the  abdomen  rises  simultaneously  with  the  thoracic  walls.  To 
discriminate  the  cause  of  the  impaired  or  lost  muscular  force, — 
whether  this  be  due  to  a  lesion  of  the  nervous  system,  or  to 
inflammation  of  the  muscle  or  of  the  adjacent  textures,  whether 
produced  by  rheumatism  or  by  lead  poisoning,  or  originating  in 
progressive  muscular  atrophy, — we  have  to  rely  chiefly  upon  the 
history  of  the  case.  In  rheumatism  of  the  diaphragm,  an  absence 
of  the  vesicular  murmur  over  the  lower  portions  of  the  chest; 
respiration  eifected  by  the  upper  ribs  exclusively ;  tense,  hard  ab- 
dominal walls ;  want  of  power  to  strain  so  as  to  aid  the  bladder 
or  intestines  in  expelling  their  contents,  ^m\h  darting,  stabbing 
pain  from  the  spine  to  the  margin  of  the  ribs  on  each  effort  to 
inspire, — have  been  particularly  noticed.*  In  fatty  degeneration 
of  the  diaphragm,  which  often  coexists  with  a  fatty  heart,  we  find, 
in  its  last  stage,  great  distress  and  difficulty  of  breathing,  and 
death  may  rapidly  follow  the  embarrassed  respiration.! 

Another  form  of  dyspnoea  is  the  so-called  Cheyne-Sfolces  resjyi- 
ration.  It  consists  in  inspirations  at  first  short,  then  deeper  and 
more  and  more  labored,  until  the  paroxysm  is  at  its  height ;  then 
becoming  shorter,  and  more  and  more  shallow,  until  the  breathing 
is  suspended.  The  pause  lasts  from  one-quarter  of  a  minute  to  a 
minute,  when  the  respiration  begins  again  in  the  same  manner, 
first  faint,  then  a  little  stronger,  then  still  stronger,  until  it  reaches 
its  height,  when  it  again  subsides  in  a  descending  scale,  to  end  in 
the  same  stand-still.  This  kind  of  breathing  is  a  very  bad  sign. 
It  is  apt  to  happen  when  from  some  cause  the  supply  of  arterial 
blood  is  cut  off  from  the  brain  or  respiratory  centre  in  the  me- 
dulla. It  is  rare  in  diseases  of  the  lungs,  much  more  common  in 
fatty  heart,  in  disease  of  the  aorta,  in  tubercular  meningitis,  in 
apoplexy  and  affections  compressing  the  medulla,  and  in  uraemia. 


*  Chapman,  Boston  IMedical  and  Surgical  Journal,  July,  1864. 
t  Callender,  London  Lancet,  Jan.  1867. 


294  MEDICAL    DIAGNOSIS. 

Cough. — Cono;li  is  a  sudden  and  violent  expiration,  having 
usually  tor  its  object  the  expulsion  of  some  annoying  sul)stance 
from  the  air-passages.  But  it  may  be  purely  nervous,  and  un- 
connected with  the  presence  of  any  irritating  matter  in  the  respi- 
ratory organs.  There  are  several  kinds  of  cough  :  according  to 
the  amount  of  expectoration,  a  cough  is  dry  or  moist ;  according 
to  its  origin,  it  is  laryngeal,  tracheal,  bronchial,  sympathetic,  etc. 

A  dry  cough  is  indicative  of  irritation.  This  is  often  seated  in 
the  larynx  and  the  trachea,  or  in  their  vicinity,  or  in  the  bronchi, 
or  in  the  lung  itself.  An  elongated  uvula,  and  many  of  the  dis- 
eases of  the  larynx  or  the  pharynx,  give  rise  to  a  dry  cough  :  it 
happens,  too,  in  pleurisy  and  in  the  earlier  stages  of  phthisis.  In 
disorders  of  the  larynx  and  trachea  the  cough  is  attended  with 
a  peculiar  shrill  noise,  or  a  hoarse  sound.  But  the  irritation 
may  not  be  situated  at  all  in  the  respiratory  system.  Affections 
of  the  liver,  stomach,  intestine,  uterus,  or  brain  will  occasion 
an  obstinate  dry  cough.  It  is  also  produced  by  dentition,  by 
the  presence  of  worms  in  the  intestinal  canal,  and  by  diseases  of 
the  organs  of  circulation.  Again,  it  may  be  strictly  nervous. 
The  brazen  cough  of  hysteria  is  dry ;  indeed,  nearly  all  sympa- 
thetic coughs  possess  a  dry  character. 

A  moist  cough  may  succeed  to  a  dry  cough.  The  moist  cough 
depends,  for  the  most  part,  on  the  presence  of  fluid  in  the  bron- 
chial tubes  or  the  lung-structure.  It  attends  bronchitis  with  free 
secretion,  oedema  of  the  lung,  the  more  advanced  stages  of  all  the 
forms  of  phthisis,  and  pneumonia  when  the  exudation  is  breaking 
up.  It  is  generally  accompanied  by  a  free  expectoration,  which 
varies  in  appearance  and  amount  with  the  morbid  state  causing  it. 

Cough  is  frequently  preceded  by  a  sensation  of  tickling  in  the 
larynx,  to  which  the  patient  is  apt  to  refer  his  whole  disorder.  It 
is  much  aifected  by  position.  Lying  down  often  increases  its 
intensity.  Sometimes  a  cough  occurs  in  severe  paroxysms.  In 
various  laryngeal  affections,  in  abscess  of  the  lung,  in  consump- 
tion, and  in  bronchial  phthisis,  such  fits  of  coughing  are  observed. 
But  in  no  complaint  are  they  so  constant  as  in  hooping-cough. 

Hooping-cough. — This  is  essentially  a  disease  of  .childhood,  and 
the  result  of  an  epidemic  influence,  or  of  contagion.  The  peculiar 
spasmodic  cough  succeeds  to  a  catarrh  of  more  than  a  week's  dura- 
tion.    During  the  paroxysms  the  eyes  fill  with  tears,  the  child's 


DISEASES    OF    THE    LUNGS,  295 

face  is  injected  and  anxious,  and  its  whole  appearance  shows  liow 
it  is  suffering  for  want  of  breath.  The  air  in  tlie  hnigs  is  expelled 
by  a  series  of  abrupt  spasmodic  expirations,  when  a  long-drawn 
inspiration,  attended  with  a  hoop,  temporarily  puts  a  stop  to  what 
appears  to  be  threatening  suffocation.  The  rest  is,  however,  sliort. 
The  cough  recommences,  and  is  again  followed  by  the  hnid  hoop- 
ing inspiration.  It  continues  in  this  manner  until,  after  a  copious 
expectoration  of  stringy  mucus,  or  after  vomiting,  the  paroxysm 
ceases,  and  a  more  lengthened  calm  ensues.  These  fits  of  cough- 
ing repeat  themselves  at  varied  intervals  during  the  twenty-four 
hours.  They  are  very  frequent  at  night.  Yet  the  child's  health 
remains  good,  in  spite  of  the  violence  of  the  attacks  and  the 
length  of  time  they  are  spread  over.  The  spasmodic  cough  lasts 
for  weeks  ;  the  hoop  then  ceases,  the  cough  loses  its  ringing  sound, 
and  gradually  leaves  entirely.  It  is  only  in  comparatively  rare 
instances  that  it  persists,  and  is  followed  by  the  development  of 
tubercles  in  the  lungs ;  just  as  it  is  only  in  exceptional  instances, 
or  in  certain  epidemics,  that  bleeding  from  the  nose  or  convulsions 
happen  during  the  violent  coughing.  In  about  one-half  the  cases 
the  cough  is  violent  enough  to  produce  ulceration  of  or  around 
the  frsenum  linguae,  from  the  force  with  which  the  tongue  is  pro- 
pelled against  the  teeth.  Frequently  the  ulcer  is  covered  with  a 
grayish  exudation  ;  it  is  never  noticed  before  the  paroxysmal  stage 
is  well  established. 

An  affection  of  so  long  duration,  marked  by  such  a  peculiar 
sign  as  a  hoop,  is  easy  of  diagnosis.  Yet  there  are  certain  con- 
ditions with  which  it  may  be  confounded.  In  its  first  stage, 
before  the  characteristic  cough  sets  in,  it  may  be  mistaken  for 
acute  bronchitis.  There  is,  indeed,  at  this  period,  no  means  of 
distinguishing  betsveen  the  two  disorders,  except  by  taking  into 
account  whether  or  not  hooping-cough  be  prevalent  as  an  epi- 
demic ;  for  it  is  only  seldom  that  the  cough  possesses  from  the 
onset  a  decided  ring.  And  bronchitis  is  in  fact  the  most  frequent 
complication,  or,  to  state  it  more  accurately,  almost  an  essential 
element,  of  tlie  malady.  It  is  usually  present  in  a  mild  form  at 
the  onset ;  it  outlasts  the  paroxysmal  stage.  At  the  height  of 
this,  a  severe  attack  of  acute  bronchitis  or  of  broncho-pneumonia 
may  temporarily  mask  the  special  traits  of  pertussis.  Again, 
occasionally  acute  bronchitis  may  exhibit  paroxysms  of  spasmodic 


296  MEDICAL   DIAGNOSIS. 

cough.  But  the  want  of  the  nervous  ek^ment  in  the  disease,  the 
absence  of  the  hoop  and  of  vomiting  and  of  the  recurring  flushing 
of  the  face,  the  dyspnoea  between  the  paroxysms,  the  decided  fever, 
do  not  permit  us  to  be  long  in  doubt. 

A  disease  less  easy  to  discriminate  from  hooping-cough  is  tuber- 
culization of  the  bronchial  glands,  or  bronchial  jjhthisis.  It,  too, 
produces  a  ringing  paroxysmal  cough.  It,  too,  occurs  in  chil- 
dren. There  is,  however,  this  difference  :  the  enlarged  bronchial 
glands  are  apt  to  press  on  the  surrounding  parts.  This  becomes 
manifest  by  the  engorgement  of  the  veins  of  the  neck,  by  the 
lividity  and  pufRness  of  the  skin,  by  the  difficulty  in  breathing  or 
in  swallowing.  The  character  of  the  voice,  also,  may  change; 
and  yet  there  may  be  no  abnormal  ph}'sical  signs  in  the  chest. 
But  often  there  is  dulness  on  percussion  between  the  scapula3, 
where  the  swollen  bronchial  glands  lie,  and  impaired  respiration 
in  portions  of  the  lung.  The  symptoms  are  those  of  pulmonary 
phthisis,  with  which  the  disease,  indeed,  may  be  associated :  there 
are  emaciation  and  the  same  loss  of  strength,  the  same  SAveating 
at  night,  the  same  hectic  fever,  the  same  tendency  to  diarrhoea. 
At  times  the  affection  of  the  glands  induces  a  chronic  pneumonia 
with  cheesy  degeneration.*  No^v,  when  we  compare  these  phe- 
nomena with  those  presented  by  hooping-cough,  Ave  miss  the  hoop, 
the  vomiting  accompanying  the  fits  of  coughing,  the  ulceration  or 
tearing  of  the  fr«num  of  the  tongue, — a  symptom  usual,  at  least, 
in  decided  cases, — the  epidemic  or  contagious  origin,  and  the  dis- 
tinct periods,  first  of  catarrh,  then  of  spasmodic  cough,  then  of 
gradual  decline.  We  see,  on  the  contrary,  an  affection  of  more 
gradual  and  uniform  progress,  which  often  proves  its  existence  by 
special  signs,  among  Avhich  a  venous  hum,  heard  when  the  steth- 
oscope is  placed  upon  the  upper  bone  of  the  sternum  while  the 
child  bends  back  the  head,  has  been  particularly  noticed.f 

When  emaciation,  hectic  fever,  and  marked  cough  are  met  with 
in  the  last  stage  of  hooping-cough,  it  is  always  highly  probable 
that  this  has  been  followed  by  a  tubercular  deposit.  It  is  not 
likely  that  such  cases  will  be  mistaken  for  those  instances  of  pul- 
monary consumption  in  which  violent    paroxysms  of  coughing 


*  Samuel  Gee,  St.  Earth.  Hosp.  Rep.,  1877. 
f  Eustace  Smith,  London  Lancet,  Aug.  187i 


DISEASES    OF    TPIE    LUNGS.  297 

occur.  The  age,  the  origin,  the  history,  are  diiferent.  Equally 
dissimilar  are  the  history  and  the  symptoms  in  other  spasmodic 
coughs,  such  as  that  of  hysteria,  or  of  some  laryngeal  affections. 

The  Sputa. — The  consistency  of  the  expectoration  varies  veiy 
much.  When  it  is  viscid  and  tough,  it  contains  a  large  amount 
of  mucus  or  muco-pus,  and  depends  generally  upon  inflammation 
or  a  hiffh  degree  of  irritation  of  the  bronchial  membrane  or  of  the 
lung  parenchyma.  When  it  is  less  tenacious,  it  has  far  less  mucus, 
and  a  preponderance  of  pus.  When  fluid  and  full  of  air,  it  floats ; 
when  dense  and  without  air,  it  sinks.  Fluid  sputum  forms  a 
homogeneous  mass ;  dense  sputum  assumes  a  round  or  irregularly 
round  shape.  When  these  purulent  masses  float  in  a  thinner 
expectoration,  we  have  the  coin-shaped  or  nummular  sputum,  so 
common  in  instances  of  pulmonary  cavities. 

The  quantity  of  the  expectoration  varies  greatly  in  different 
diseases  of  the  lungs.  In  the  most  acute  stages,  or  in  spreading 
inflammations,  it  is  usually  small,  and  increases  as  the  difficulty 
lessens.  In  bronchial  dilatation,  in  pulmonary  abscesses,  es- 
pecially when  they  burst,  and  in  the  voiding  of  a  collection  of 
pus  in  the  pleura  through  the  bronchial  tubes,  the  amount  dis- 
charged is  very  large. 

The  color  of  the  sputum  depends  a  great  deal  on  its  constituents. 
When  mucous,  it  is  white ;  when  muco-purulent,  yellowish  or  yel- 
lowish-green ;  when  purulent,  generally  greenish  or  of  a  yellow- 
green.     It  is  also  tinged  by  bile,  by  pigment,  and  by  blood. 

Sputum  consists  chiefly  of  water,  albumen,  and  mucin.  Mi- 
nutely examined  it  exhibits  pavement  and  columnar  epithelium, 
pus-corpuscles,  blood-globules,  various  forms  of  crystals,  such  as 
the  slender  needles  of  the  fatty  acids,  and  peculiar  spindle-shaped 
bodies,  fibrinous  coagula,  fungous  growths,  and  elastic  fibres. 
The  latter  and  the  fatty  acids  are  encountered  in  diseases  in- 
volving destruction  of  the  lung-tissue.  The  fungous  gi'owths  are 
most  common  in  the  sputum  from  cavities,  in  putrid  bronchitis, 
and  in  gangrene.  Fibrinous  masses  are  particularly  associated 
with  acute  pneumonia  and  with  plastic  bronchitis.  Special  bac- 
teria, as  the  bacillus  of  tuberculosis,  are  found  in  the  sputum  of 
phthisis ;  and  the  minute  appearances  in  the  sputum  may  lead  to 
the  diagnosis  of  cancer  and  of  actinomycosis  of  the  lungs. 

Haemoptysis. — Sputa  are  streaked  with  blood  in  bronchitis. 


298  HIEDICAL    DIAGNOSIS. 

iiitininti'ly  admixed  Mitli  blood  in  pneumonia;  yet  we  do  not  call 
this  lueiuoptysis.  It  is  only  when  a  eertain  quantity  of  pure 
blood  is  cxpectorattxl  that  the  complaint  is  regarded  as  hsemoptysis, 
or  hemorrhage  from  the  huiiis.  Now,  a  pulmonary  hemorrhage 
may  be  an  idiopathic  affection  ;  but  it  is  not  often  so.  It  is  mostly 
symptomatic  of  a  grave  disease  of  the  lungs  or  the  heart,  and 
usually  of  tubercular  consumption.  It  is  at  times  a  discharge 
which  takes  the  place  of  a  suppressed  flow  of  blood  from  another 
part  of  the  body,  as  in  vicarious  menstruation. 

AVhen  called  to  a  person  who  has  been  spitting  blood,  we  hav^e 
first  to  solve  the  question,  Where  does  the  blood  come  from  ?  It 
may  issue  from  the  nose  or  mouth  ;  from  the  trachea  ;  from  the 
oesophagus  or  stomach ;  it  may  stream  from  an  aneurism  which 
has  burst  into  the  air-passages ;  or  it  may  be  that  the  lung  is 
bleeding. 

When  in  epistaxis  the  blood,  instead  of  flowing  out  of  the  nostrils, 
flows  backward,  it  is  coughed  up.  But  on  the  }iatient  inclining 
forward,  it  will  issue  from  the  nose.  The  color  of  the  blood  is  not 
florid  ;  and  it  can  be  seen  trickling  down  the  pharynx.  Inspec- 
tion is  of  equal  service  when  the  blood  comes  from  any  part  of 
the  oral  cavity ;  especially  if  it  proceed  from  the  gums.  Their 
swollen  state,  their  spongy  appearance,  and  the  readiness  with 
which  they  bleed  when  pressed,  point  out  at  once  the  source  of 
the  hemorrhage. 

Loss  of  blood  from  the  larynx  and  the  trncJica,  or  from  the 
oesophagus,  is  exceedingly  i-are ;  and  when  it  docs  occur,  it  is  de- 
pendent upon  some  local  lesion,  or  the  presence  of  ,some  foreign 
substance  which  has  been  swallowed.  By  attention  to  the  history, 
then,  we  can  recognize  the  cause  and  the  seat  of  the  hemorrhage. 
The  blood  itself  furnishes  no  certain  mark  of  distinction.  Occa- 
sionally the  hemorrhage  takes  place  into  the  interior  of  the  larynx, 
and  only  a  very  small  quantity  of  blood  is  expectorated.  Cases 
of  hemorrhagic  laryngitis  are  usually  connected  with  catarrhal 
inflammation  of  the  windpipe  ;  they  are  accompanied  by  severe 
dyspnoea,  and  with  the  laryngeal  mirror  the  blood  can  be  seen 
trickling  down  the  windpipe. 

When  blood  is  vomited  from  the  stomach,  it  is  preceded  by 
a  feeling  of  weight  and  uneasiness  in  the  epigastric  region,  and 
sometimes  by  decided  nausea.     The  ejected  matter  consists  of  a 


DISEASES    OP    THE    LUNGS.  299 

dark  grumous  blood,  thus  altorod  hy  the  gastric  juice,  and  is  often 
mixed  with  broken-down  food.  Its  dark  color  is  invariable,  ex- 
cept wliere  an  artery  has  been  laid  bare  by  an  ulcer,  in  which 
case  a  sudden  discharge  of  florid  blood  takes  place.  Thei'c  is  not 
commonly  more  than  one  act  of  vomiting ;  the  blood  which  re- 
mains in  the  stomach  passes  into  the  intestines,  and  goes  off  with 
the  stools.  Hcematemesis  is  attended  with  tenderness  at  the  epi- 
gastrium. It  is  usually  symptomatic  of  an  organic  affection  of 
the  stomach,  liver,  intestine,  or  spleen  ;  it  may,  however,  depend 
upon  the  swallowing  of  irritating  poisons ;  or  happen  in  fevers  or 
in  scurvy,  or  as  a  substitute  for  suppressed  discharges. 

The  blood  which  gushes  out  of  the  mouth  when  an  aneurism 
opens  into  the  air-passages  is  red  and  arterial.  It  spurts  out 
in  jets,  and  the  patient  rarely  long  survives  the  hemorrhage. 
Should  this  not  prove  quickly  fatal,  we  are  seldom  at  a  loss  to 
determine  the  cause  of  the  bleeding ;  for  we  find  the  physical 
signs  of  the  aneurismal  tumor  in  the  chest. 

But  when  the  blood  comes  from  the  lungs,  it  presents  charac- 
ters and  is  connected  with  symptoms  totally  different  from  any 
of  those  just  mentioned.  The  bleeding  is  preceded  by  a  sense  of 
weight  and  of  uneasiness  in  the  chest.  The  patient  perceives  a 
saltish  taste, in  the  mouth  and  a  tickling  sensation  in  the  larynx, 
when  suddenly  the  mouth  fills  with  blood,  or  after  a  slight  cough 
he  expectorates  a  quantity  of  light-red  and  frothy  blood.  His 
anxiety  becomes  great ;  the  skin  is  covered  with  a  cold  sweat ; 
the  pulse  is  quick  and  bounds  under  the  finger.  He  spits  up 
more  blood,  and  this  continues  to  come  up  at  varying  intervals 
and  in  changing  quantities  all  day,  or  for  several  days,  or  even 
for  a  much  longer  period.  It  is  at  first  pure  blood,  or  mixed 
with  the  sputum ;  is  red  and  not  coagulated,  and  frothy,  except 
when  the  hemorrhage  is  very  profuse.  But  after  one  or  two 
bleedings,  the  matter  which  is  coughed  up  contains  dark  clots, 
being  the  blood  which  has  been  retained  somewhere  in  the  air- 
passages  since  the  previous  attack.  The  blood  is  never,  at  the 
onset  of  the  hemorrhage,  dark  and  grumous ;  yet  in  rare  cases 
it  has  more  of  a  venous  than  of  an  arterial  hue.  The  amount 
which  is  brought  up  at  one  bleeding  ranges  from  one  to  two 
drachms  to  as  many  pints ;  but  the  quantity  that  comes  out  of 
the  mouth  is  by  no  means  an  index  of  the  quantity  extravasated. 


300  MEDICAL    DIAGNOSIS. 

The  blood  may  be  eifuscd  into  the  puhiionarv  structure,  and  but 
little  be  expelled. 

.Vfter  tlie  description  above  given,  it  is  unnecessary  to  point  out 
the  marks  of  discrimination  between  blood  ejected  from  the  lungs 
and  blood  from  other  parts.  The  symptoms  are  different;  the 
blood  itself  is  different.  And  listening  to  the  chest  detects  bub- 
bling sounds  in  the  air-tubes;  still,  to  find  these  is  not  requisite 
for  the  diagnosis  of  pulnumary  hemorrhage,  and  indeed,  while 
the  bleeding  is  going  on,  the  patient's  welfare  forbids  an  extended 
thoracic  examination.  But  as  soon  as  circumstances  permit,  that 
examination  becomes  of  immense  value  by  showing  us  with  Avhat 
morbid  state  the  hemorrhage  is  connected,  and  whether  the  bleed- 
ing is  symptomatic  of  a  disease  of  the  heart  or  the  lungs,  or  does 
not  depend  upon  either.  It  is  mostly  owing  to  an  affection  of 
the  heart  or  the  lungs,  and  is  exceedingly  prone  to  be  repeated. 

Yet  the  lungs  may  bleed  frequently  without  there  being  an 
organic  lesion  within  the  chest  to  account  for  the  hemorrhage.  I 
had,  some  years  ago,  a  patient  under  my  care  who  had  been  spit- 
ting blood  daily  for  five  years.  Although  enfeebled  by  the  loss 
of  blood,  his  general  health  remained  good.  His  lungs  and  heart 
appeared  to  be  soimd.  Another  patient  had  pulmonary  hemor- 
rhages at  varying  intervals  for  eighteen  months.  He  finally  died 
of  exhaustion  ;  but  he  never  presented  any  physical  signs  of  tho- 
racic disease.  An  examination  of  the  body  was,  unfortunately,  not 
permitted.  But  in  the  case  of  a  gentleman  that  I  had  watched 
for  years,  the  repeated  hemorrhages  Avere  found  at  the  autopsy  to 
be  unconnected  with  disease  of  the  lungs.  He  died  of  an  acute 
disease  complicated  with  pleurisy. 

In  these  instances  the  hemorrhages  recurred  often.  But  we 
meet  with  robust  persons  in  whom  the  loss  of  blood  follows 
active  exercise  or  exertion  and  is  not  apt  to  be  protracted.  In 
such  cases,  of  which  I  have  seen  a  number  in  soldiers  sent  to 
hospitals  after  the  fatigue  of  a  long  march  or  the  excitement 
of  a  battle,  simple  congestion  of  the  lungs  is  probably  the  cause 
of  the  disorder. 

Except  under  the  circumstances  mentioned,  haemoptysis  is  a 
grave  symptom.  It  is  not  dangerous  as  regards  its  immediate 
termination,  but  dangerous  because  it  is,  for  the  most  part,  the 
indication  of  a  serious  malady.      Few  die  as  the  direct  conse- 


DISEASES   OF   TPIE   LUNGS.  301 

qnence  of  the  hemorrhage,  but  many  die  of  the  disorder  of  wliich 
the  hemorrhage  is  the  consequence. 

Diseases  in  which  Clearness  on  Percussion  is  met  with  and 
constitutes  a  Valuable  Sign. 

Some  of  these  ailments  are  acute,  others  chronic ;  and  nearly 
all  have  as  their  prominent  symptom  a  cough,  and  are  affections, 
or  follow  affections,  of  the  bronchial  tubes. 

Acute  Bronchitis. — This  is  an  acute  catarrhal  inflammation 
of  the  bronchial  mucous  membrane,  which  occurs  idiopathically, 
or  happens  as  a  secondary  complaint  in  the  course  of  fevers, 
of  rheumatism,  and  of  cardiac  disorders.  Let  us  examine  the 
manifestations  of  the  idiopathic  malady. 

Bronchitis  varies  considerably  according  to  the  size  of  the  tubes 
involved.  A^hen  the  smaller  tubes  are  affected,  a  disease  called 
capillary  bronchitis,  or  suffocative  catarrh,  is  established,  the  prog- 
nosis of  which  is  very  grave,  and  the  diagnosis  of  which  presents 
points  for  special  consideration. 

The  symptoms  of  acute  bronchitis  of  the  large  and  middle-sized 
tubes  are,  a  sensation  of  tickling  in  the  throat,  soreness  or  pain 
behind  the  sternum,  a  slight  oppression  in  breathing,  rather  hur- 
ried respiration,  and  a  paroxysmal  cough.  Let  us  add  to  these 
pain  in  the  limbs,  coryza,  and  a  fever  of  moderate  intensitv, 
and  we  have  the  main  phenomena  met  with  during  the  onset 
and  at  the  height  of  an  attack  of  ordinary  acute  bronchitis.  The 
fits  of  coughing  in  the  earlier  stages  are  followed  by  a  clear, 
frothy  expectoration,  which,  as  the  cough  becomes  looser  and  less 
fatiguing,  changes  from  an  almost  transparent  fluid  to  a  yellow- 
ish or  greenish  sputum.  This  may  be  uniform  or  streaked  with 
blood ;  it  may  be  small  in  amount,  or  in  large  quantities.  The 
fever  soon  leaves;  but  long  after  it  has  ceased,  the  patient  still 
has  a  cough  and  expectoration,  both  of  which  only  gradually 
disappear. 

The  physical  signs  may  be  inferred  from  the  lesions.  As  there 
is  no  condensation  of  pulmonary  tissue,  there  is  no  dulness  on 
percussion,  the  thickening  and  injection  of  the  bronchial  mucous 
membrane  not  being  sufficient  to  modify  materially  the  normal 
resonance.  But  these  conditions  must  alter  the  respiratory  mur- 
mur.    They  bring  out  more  of  the  bronchial  element  of  sound, 


302  MEDICAL   DIAGNOSIS. 

hence  more  expiration  with  the  coarser  inspiration, — in  other 
words,  a  harsh  respiration  ;  or  the  swelling  obstructs  the  entrance 
of  air  into  the  air-vesicles,  and  enfeebles  the  vesicular  nun-mur. 
Again,  new  sounds,  the  rales,  are  produced ;  first  dry,  then  moist. 
This  succession  of  the  rales  is,  however,  not  absolute,  and  depends, 
to  a  o-reat  deurce,  on  the  density  of  the  fluid  in  the  bronchial  tubes. 
Dry  rales,  mixed  with  moist,  may  be  perceived  even  in  the  later 
stages  of  acute  bronchitis,  and  long  after  the  febrile  signs  have 
ceased.  In  fact,  the  tenacity  alone  of  the  exudation  determines 
the  nature  of  the  rales,  and  even  somewhat  their  exact  character ; 
for  every  dry  rale  is  not  precisely  like  every  other  dry  rale,  nor 
every  moist  rale  equally  moist.  With  reference  to  size,  the  sono- 
rous rales  and  the  large  bubbling  sounds  prevail  when  the  disorder 
attacks  the  larger  tubes.  Sometimes,  when  the  bronchial  inflam- 
mation is  severe  and  extensive,  we  find  a  sound  which  seems  to  be 
neither  a  dry  nor  a  bubbling  rale,  but  rather  a  compound  of  both, 
— a  dry  sound,  yet  not  continuous,  giving  the  idea  of  being  caused 
by  the  breaking  up  of  fluid.  Or,  there  may  be  a  mixture  of  the 
sounds  of  respiration  with  the  rales,  occasioning  a  peculiar  kind 
of  breathing, — one  in  which  we  can  recognize  neither  a  distinctly 
vesicular  nor  a  distinctly  bronchial  element,  nor  a  well-defined 
rale.  All  these  states  are  dependent  upon  the  amount,  and,  above 
all,  upon  the  condition,  of  the  exudation  in  the  bronchial  tubes. 
But  thev  indicate  nothing  beyond  the  fact  that  there  is  an  exu- 
dation present  Avhich  is  very  large  in  quantity  and  tenacious  in 
character.  When  the  sounds  are  of  the  indeterminate  nature  just 
alluded  to,  the  vibrations  produced  in  the  tubes  are  apt  to  be 
transmitted  to  the  parietes  of  the  chest,  occasioning  with  each 
respiration  a  marked  fremitus. 

The  diagnosis,  then,  of  acute  bronchitis  is  determined  by  the 
cough,  the  fever,  the  expectoration,  and  the  signs  of  clearness  on 
percussion,  diffused  rales,  or  harsh  respiration.  From  all  those 
diseases  of  the  lung  which  result  in  the  consolidation  of  the  pul- 
monarv  tissue,  such  as  jmeumonia  and  tuberculosis,  we  distinguish 
bronchitis  by  the  absence  of  dulncss  on  percussion.  Some  cases 
of  acute  consumption,  on  account  of  the  sudden  invasion  of  the 
malady  and  the  general  diffusion  of  the  physical  signs,  are  liable 
to  be  mistaken  for  acute  bronchitis ;  but  the  different  j^rogress  of 
the  disorder  usually  clears  up  all  doubt.     Error  in  diagnosis  is 


DISEASES    OF    THE    LUNGS.  303 

more  likely  to  arise  from  the  habit,  when  the  signs  of  bronchitis 
have  been  made  out,  of  not  looking  further ;  forgetting,  in  the 
attention  to  the  disease  within  the  thorax,  the  various  morbid 
states  which  bronchitis  may  accompany,  and  particularly  its  fre- 
quent association  with  fevers. 

Capillary  Bronchitis. — This  is  a  disease  of  the  aged  and  of 
young  children.  It  begins  with  an  acute  inflammation  of  tlie 
larger  bronchi ;  or  the  disorder  may  from  the  onset  affect  the 
smaller  tubes.  In  either  case,  signs  of  obstructed  circulation  soon 
manifest  themselves ;  there  is  lividity  of  the  lips  and  cheeks,  with 
hurried  breathing,  a  rapid  pulse,  an  anxious  countenance,  great 
restlessness,  moderate  fever  temperature,  and  a  cough,  followed 
by  viscid  expectoration.  As  the  malady  advances,  the  color  of 
the  skin  and  the  mucous  membranes  shows  more  and  more  the 
want  of  properly-aerated  blood  ;  the  sputa  cease  with  the  failing 
strength ;  and  in  old  persons  delirium  and  coma,  in  young  chil- 
dren convulsions,  mark  the  closing  struggle. 

The  physical  sigus  are  those  of  ordinary  bronchitis,  but  modi- 
fied by  the  seat  of  the  malady.  High-pitched  Avhistling  sounds, 
accompanied  or  superseded  by  very  fine  moist  rales,  denote  the 
smaller  size  of  the  tubes  involved.  The  resonance  on  percussion 
is  clear,  or  very  slightly  different  from  that  of  health.  When 
materially  duller,  it  indicates  that  the  pulmonary  tissue  itself 
shares  in  the  inflammation,  or  that  it  has  been  exhausted  of  its 
air  and  has  collapsed. 

The  parts  of  the  lung  which  the  physical  signs  prove  to  bear 
the  brunt  of  the  disease  are  the  lower  lobes.  In  the  upper  there 
may  be  large  rales  and  some  fine  ones ;  but  it  is  low  down  and  at 
the  posterior  portion  of  the  chest  that  the  fine  sounds  are  most 
abundant.  Yet  when  the  inflammation  is  extensive,  and  the 
accumulation  of  secretions  and  morbid  products  great,  quantities 
of  small  rales  are  heard  at  every  part  of  the  chest. 

From  this  description  of  capillary  bronchitis  it  will  be  ap- 
parent that  it  diflFers  from  ordinary  acute  bronchitis  in  the  greater 
tendency  to  prostration  and  to  suffocation,  in  the  signs  of  im- 
perfect aeration  of  the  blood,  and  in  the  fineness  of  the  rales. 

Like  the  more  usual  kind  of  acute  bronchial  inflammation, 
capillary  bronchitis  is  liable  to  be  mistaken  for  acute  lobar  pneu- 
monia and  for  phthisis.      And  in  the  majority  of  cases  the  same 


304  MEDICAL    DIAGNOSIS. 

rules  serve  for  its  discrimination  ;  the  absence  of  percussion  clul- 
ness  and  the  diffusion  of- the  morbid  sounds  arc  here  aoain  of 
tlie  utmost  value.  The  raijidity  of  the  attack  and  the  signs  of 
suffocation  might  mislead  into  the  supposition  of  the  existence 
of  a?denia  of  the  glottis,  of  laryngitis,  or  of  croup  ;  errors  in 
diagnosis  which  the  detection  of  fine  chest  rales  will  prevent. 

Cai)illary  bronchitis  is  apt  to  be  confounded  with  catarrhal  or 
hvoncho-pneuinonia, — a  form  of  inflammation  of  the  lung  occur- 
ring mainly  in  children,  and  following  bronchial  catarrh  or  pul- 
monary collapse.  The  disease  is  most  commonly  observed  in 
connection  with  measles,  hooping-cough,  influenza,  or  diphtheria  ; 
it  is  especially  likely  to  be  seen  in  children  previously  in  impaired 
health  or  scrofulous  or  rachitic.  It  is  apt  to  be  attended  by  cere- 
bral symptoms,  by  paroxysms  of  dyspncea,  and  by  high  and  irreg- 
ular fever.  As  it  is  limited  to  the  lobules,  it  yields  but  imperfect 
signs  of  consolidation.  The  bronchial  breathing  is  rarely  very 
marked ;  crepitant  rale  is  not  usually  perceived,  or  can  scarcely  be 
distinguished  from  the  small  bubbling  sounds  of  fine  bronchitis ; 
and,  from  the  usual  association  with  inflammation  of  the  fine 
bronchial  tubes,  it  is  in  individual  cases  often  extremely  diffi- 
cult to  say  whether  portions  of  the  lung-tissue  are  consolidated. 
Theoretically,  broncho-pneumonia  may  be  distinguished  from 
bronchitis  by  the  dulness  on  percussion  ;  practically,  this  aids  but 
little.  Dulness  on  percussion  is  in  children  difficult  to  elicit ; 
and,  again,  a  dulness  may  be  temporarily  produced  in  capillary 
bronchitis  by  collapse  of  the  pulmonary  tissue.  There  are,  there- 
fore, no  absolute  signs  of  difference.  Still,  we  may  suspect  that 
the  inflanmiation  has  infiltrated  the  lobules,  if  the  breathing  be 
very  rapid,  the  fever  severe,  or  the  temperature,  which  is  rarely 
above  102°  in  the  preceding  bronchitis  of  the  finer  tubes,  rise 
suddenly  by  several  degrees ;  if  the  cough  lessen  as  the  pneumo- 
nia develops,  if  laryngeal  symptoms  arise,  and  if,  in  addition  to 
rales,  not  very  diffused,  spots  of  dulness,  which  do  not  change 
their  seat,  and  do  not  disappear  under  respiratory  percussion,  be 
discerned,  and  plastic  pleurisy  appear  as  a  complication.  On  the 
other  hand,  when  there  are  most  marked  signs  of  deficient  aeration 
of  blood ;  when  the  child  seems  to  suffocate  from  want  of  power 
to  expectorate ;  when  a  multitude  of  fine  dry  and  moist  sounds 
are  heard  at  every  part  of  the  chest,  and  little  or  no  corresponding 


DISEASES    OF    THE    I.UNGS.  305 

impairment  of  resonance  on  percussion  is  detected, — we  know  that 
the  capillary  bronchi  are  extensively  filled  with  pus  and  morbid 
secretions,  and  that  true  suffocative  catarrh  is  threatening  life. 
Capillary  bronchitis  is  a  rapid  disease ;  catarrhal  pneumonia  runs 
a  much  slower  course,  generally  lasting  weeks. 

Chronic  Bronchitis. — The  symptoms  and  signs  of  chronic 
bronchitis  are  not  very  different  from  those  of  the  ordinary  form 
of  acute  bronchitis.  The  duration  of  the  complaint  and  the 
absence  of  marked  fever  are  the  chief  distinguishing  elements. 
Yet  the  cough,  although  on  the  whole  chronic,  is  far  from  being 
constant.  It  may  disappear  almost  altogether,  and  then  reappear 
with  more  than  its  previous  severity  ;  and  this  state  of  things  may 
go  on  for  years,  undue  exposure  and  change  of  season  aggravating 
the  disorder. 

The  sputa  vary,  even  more  than  in  acute  bronchitis,  in  tenacity 
and  quantity.  There  may  be  merely  a  small  quantity  of  yellowish 
matter  expectorated  in  the  morning,  or  an  almost  continued  flow 
from  the  bronchial  tubes, — bronchorrhcea.  The  physical  signs 
differ  accordingly.  A  harsh  or  feeble  respiration,  and  few  or 
many,  either  dry  or  moist,  rales,  are  present,  in  conformity  with 
the  state  of  the  bronchial  mucous  membrane  and  of  its  secretions. 
The  sound  on  percussion  is  clear.  Excessive  secretions  somewhat 
impair  the  pulmonary  resonance,  but  only  temporarily ;  for  with 
the  shifting  secretions  shifts  the  very  slight  dulness. 

One  of  the  most  important  points  in  the  diagnosis  of  chronic 
bronchitis  is  to  attend  to  the  manner  in  which  it  arises.  It  may 
follow  a  seizure  of  acute  bronchitis,  or  be  the  result  of  recurrino- 
attacks  of  subacute  character ;  it  may  appear  as  a  primary  affec- 
tion, or  it  may  follow  the  exanthemata ;  or,  again,  it  may  com- 
plicate some  previously-existing  disorder,  as  Bright's  disease, 
rheumatism,  lithsemia,  gout,  psoriasis,  or  eczema,  and  be  directly 
traceable  to  the  constitutional  taints  of  these  maladies ;  and  its 
symptoms  will  vary  and  be  influenced  by  those  of  the  general 
malady  to  which  it  is  subordinate. 

In  the  ordinary  idiopathic  malady  the  general  health,  as  a  rule, 
suffers  but  little.  In  some  instances,  however,  emaciation  takes 
place,  and  the  disease  simulates  phthisis.  This  is  particularly 
the  case  in  the  bronchial  affections  among  knife-grinders  and 
coal-miners,  also  in  those  of  granite-masons,  of  sandpaper-makers, 

20 


306  MEDICAL    DIAGNOSIS. 

of  flax-dresscrs,  and  of  potters.  The  resemblance  becomes  still 
greater  .when  superadded  bronchial  dilatation  and  Hbroid  indura- 
tion of  the  lung  produce  physical  signs  like  those  of  pulmonary 
con^um})tion.  Ordinarily  the  chronicity  of  the  cinigh,  the  occa- 
sional subacute  exacerbations,  the  small  amount  of  constitutional 
disturbance,  the  ]xist-sternal  })ain,  the  diti'usiou  of  the  signs  dis- 
cerned on  auscultation,  and  the  clearness  on  percussion,  constitute 
a  group  of  phenomena  which  does  not  permit  an  error. 

A  chronic  catarrhal  inflammation  of  the  mucous  membrane  of 
the  nose  may  be  mistaken  for  chronic  bronchitis,  with  which,  in- 
deed, it  may  coexist.  But  when  occurring  uneombinecl,  there  are 
no  rales  in  the  chest  or  altered  breathing-sounds  indicative  of  dis- 
order there,  though  there  may  be  a  cough,  from  the  throat  being 
also  affected.  The  secretion,  too,  from  the  nose  is  very  copious 
and  of  muco-purulent  character,  the  upper  part  of  the  nose  looks 
somewhat  flattened,  and  the  sense  of  smell  is  impaired, — not  one 
of  which  signs  is  met  with  in  chronic  bronchitis. 

It  seems  almost  unnecessary  to  speak  of  the  differential  diag- 
nosis between  chronic  bronchitis  and  rose  cold  and  liay  asthma. 
The  coexistence  of  marked  signs  of  irritation  of  the  eyes,  nose, 
and  throat ;  the  appearance  of  the  distressing  affections  at  a  par- 
ticular period  of  the  year ;  the  fixed  time  in  which  they  run  their 
course  ;  the  almost  instant  relief  on  leaving  the  regions  where  the 
attack  has  been  brought  on  and  on  reaching  favorable  localities ; 
the  depression  of  the  nervous  system ;  and,  on  the  other  hand, 
the  less  decided  signs  of  bronchial  affection, — clearly  distinguish 
the  maladies. 

We  meet  occasionally  with  a  form  of  bronchitis  in  which  the 
expectorated  matter  is  solid.  This  plastic  bronchitis  presents  all 
the  usual  signs  and  symptoms  of  bronchial  inflammation.  It  may 
be  chronic,  or  it  may  be  acute.  It  is  most  frequently  chronic,  with 
occasional  acute  or  subacute  exacerbations.  The  disease  extends 
in  this  way  over  weeks,  months,  or  even  years,  and  is  apt  to  end 
in  complete  recovery.  But  in  its  acute  form  it  is  a  complaint  of 
great  danger  and  accompanied  by  much  dyspnoea,  and  has  led  to 
death  by  suffocation.*     Males,  as  we  find  by  looking  at  the  cases 

*  Andral ;  also  Hilton  Fagge,  Trans,  of  Path.  Soc,  vol.  xvi. ;  Biermer,  Vir- 
chow's  Handbueh  der  Pathologie ;  Kiegel,  in  Ziemssen's  Cyclopasdia;  Glascow, 
Trans,  of  Amer.  Med.  Association,  1879  ;  Prager  Med.  'Wochenschr., 


DISEASES    OF    THE    LUiSCiS.  307 

which  Peacock  *  has  collected,  are  more  often  attacked  than  females. 
The  same  carefully-collated  observations  show  that  the  disorder 
affects  more  commonly  the  upper  than  the  lower  part  of  the  lungs. 
As  regards  the  physical  signs,  Fuller,t  who  has  met  with  a  num- 
ber of  well-marked  examples  of  the  complaint,  states  that  there  is 
weakness  or  entire  absence  of  breathing  over  the  affected  portions 
of  the  lungs,  and  that,  from  attending  collapse,  complete  and  rap- 
idly-developed dulness  on  percussion  may  ensue.  But  the  only 
absolutely  diagnostic  phenomenon  is  the  peculiar  membranous  ma- 
terial expectorated.  In  form  this  may  be  either  in  thin  shreds,  or 
moulded  into  an  accurate  cast  of  a  bronchial  tube  and  its  ramifica- 
tions. The  expectoration  of  the  firm  bodies  is  sometimes  attended 
with  copious  haemoptysis. 

The  little  round  solid  pellets  which  consumptive  patients  or  even 
some  persons  in  good  health  cough  up,  from  time  to  time,  are  the 
result  of  a  plastic  bronchitis  on  a  very  limited  scale.  A  kindred 
disease  to  plastic  bronchitis  has  been  described  as  ''bronchiolitis 
exsudativa."  The  sputum  is  grayish  and  very  tenacious,  and  full 
of  spirilla  which  come  from  the  bronchioles.  Gradually-increasing 
dyspnoea  and  attacks  of  asthma  are  prominent  symptoms. J 

Another  variety  of  chronic  bronchitis  is  putrid  bi'onehitls.  This 
may  happen  in  connection  with  bronchial  dilatation  or  with  chronic 
pneumonia,  or  without  these  conditions ;  occasionally  it  appears 
after  a  suppurative  pleurisy  which  has  broken  into  the  lung. 
There  is  fever  with  irregular  temperature  ;  at  times  chills  occur. 
The  distressing  cough  is  followed  by  a  copious,  half-liquid  sputum, 
extremely  offensive.  The  peculiar  odor  is  thought  to  be  due  to 
a  micro-organism,  especially  to  a  short,  slightly-curved  bacillus 
described  by  Lumniezer.§      Cases  of  putrid  bronchitis  may  be 

*  Transactions  of  the  Pathological  Society,  vol.  v. ;  Medical  Times  and 
Gazette,  vol.  ix. ;  also  De  Havilland  Hall,  St.  Earth.  Hosp.  Eep.,  1877. 

f  Diseases  of  the  Chest;  also  A.  Jacohson,  Arch,  f  Klin.  Chir.,  Berlin,  1886, 
xxxiii.  ;  J.  Singer,  Prager  Med.  Wochenschr.,  1886,  xi. ;  Yon  Starck,  Berlin. 
Klin.  Wochenschr.,  1886,  xxiii.  ;  M.  J.  Madigan,  Med.  Standard,  Chicago, 
1887,  ii. ;  H.  A.  Johnson,  Chicago  Med.  Journ.  and  Exam.,  1887;  also  Journ. 
Amer.  Med.  Assoc,  Chicago,  1887,  viii. ;  W.  K.  Patton,  Chicago  Med.  Journ. 
and  Exam.,  1887;  W.  S.  Davis,  Journ.  Amer.  Med.  Assoc,  1887;  Ninaus, 
Wien.  Mediz.  Wochenschr.,  April  7,  1888. 

X  Curschmann,  Deutsch.  Arch,  fiir  Klin.  Med.,  Nov.  1882. 

I  Wien.  Mediz.  Presse,  Maj',  1888. 


308  MEDICAL    DIAGNOSIS. 

mistaken  for  gangrene  of  the  lung ;  but  the  odor  is  different,  and 
they  laek  the  physieal  signs  of  king  destruction,  and  ekistic  fibres 
in  file  sputum.  We  must,  however,  bear  in  mind  that  putrid 
bronchitis  may  terminate  fatally  by  induced  pulmonary  gangrene. 

Emphysema. — A  distention  of  tiie  air-cells  is  a  fre(]uent 
sequel  of  chronic  bronchitis.  It  may  happen  in  only  one  lung ; 
but  the  air-vesicles  of  both  are  usually  distended.  The  effect  of 
this  is  to  obliterate  some  of  the  capillaries,  and  to  interfere  with  a 
flow  of  blood  through  the  lungs.  From  this  proceed,  to  a  great 
extent,  the  feeling  of  constriction  and  the  dyspnoea,  the  anxious 
look,  the  bluish  lip,  of  emphysematous  patients,  and  the  tendency 
the  disease  has  to  produce  dilatation  or  dilated  hypertrophy  of  the 
right  side  of  the  heart. 

Emphysema  is  essentially  a  chronic  malady ;  but  in  its  course 
subacute  attacks  of  bronchitis  occur  Avhich  much  augment  the 
difficulty  of  respiration.  The  embarrassment  in  breathing  is, 
indeed,  the  most  prominent  of  the  symptoms.  It  is  not  so  much 
the  difficulty  of  getting  air  into  the  lung,  as  it  is  of  getting  it  out, 
which  annoys  the  patient.  He  breathes  as  if  he  had  no  object 
but  that  of  forcing  the  air  out  of  the  pulmonary  tissue.  And 
this  task  is  often  aggravated  by  spasmodic  narrowing  of  the 
bronchial  tubes :  hence  it  is  very  common  to  meet  with  the  loud 
M'heezing  of  asthma  in  those  whose  air-cells  are  permanently 
dilated.  In  long-standing  cases  of  the  disease  the  patient  looks 
cachectic,  and  dropsy  of  the  feet  is  noticed.  There  may  be  also  a 
chronic  cough. 

The  physical  signs  of  emphysema  are  easily  dcduciblc  from 
the  pathological  conditions.  The  distention  of  the  lung-tissue 
explains  the  great  prominence  and  fulness  of  the  chest,  and  the 
displacement  of  the  liver  or  heart.  The  ringing  clearness  on 
percussion — at  times  almost  tympanitic  in  its  character — and 
the  increased  resistance  to  the  finger  have  the  same  cause.  Nor 
is  it  difficult  to  understand  how  the  loss  of  elasticity  in  the  dilated 
air-cells  will  give  rise  to  an  unchanged  note  on  respiratory  jjercus- 
sion,  to  prolonged  expiration,  and  to  a  feeble  inspiratory  murmur. 
If  bronchitis  coexist,  the  signs  on  auscultation  are  necessarily 
somewhat  altered.  The  respiration  is  harsh,  or  intermixed  with 
dry  and  moist  rales.  The  former  especially  assume  great  promi- 
nence, and  are  heard  as  sonorous,  or  still  oftener  as  sibilant,  rales. 


DISEASES   OF   THE    LUNGS. 


309 


(luring  the  prolonged  and  labored  act  of  expiration.  Occasionally 
a  crackling  sound  is  heard  in  emphysema.*  When  the  emphy- 
sema is  partial,  all  these  signs  are  limited;  when  it  is  more  general, 
they  are  diffused. 

If  the  upper  lobe  of  the  right  lung  or  the  lower  lobe  of  the 
left,  Avhich,  according  to  Loiiis,t  are  the  parts  most  frequently 

Fig.  23. 


Appearance  of  the  chest  in  a  patient  suffering  from  a  high  degree  of  emphysema. 
The  h'-art  is  cli>placed.  The  other  phj'sical  signs  are  extreme  percussion  clearness; 
a  feeble,  hardly  audible  inspiration ;  a  very  prolonged  expiration. 

affected,  be  emphysematous,  the  visible  local  bulging  might  mis- 
lead into  the  idea  of  the  prominence  being  due  to  an  aneurismal 
tumor,  or  to  the  presence  of  fluid  in  the  pleural  cavity.  Any 
doubt  will,  however,  be  dispelled  by  a  careful  examination  of  the 
chest.  The  dulness  over  an  aneurismal  tumor,  its  pulsation,  and 
its  sounds,  are  different  from  the  exaggerated  clearness  on  percus- 
sion and  the  changed  respiratory  murmur  of  an  emphysematous 


*  Gerhardt,  Berlin.  Klin.  Wochenschr. ,  March  12,  1888. 
f  Mem.  de  la  Soc.  Med.  d' Observation,  tome  i. 


310  MEDICAL   DIAGNOSIS. 

lung".  Pleuritic  effiLsions  produce  a  bulging-  at  the  lower  part  of 
the  thorax.  But,  although  there  may  be  a  very  clear,  or  rather  a 
tympanitic,  sound  above  the  fluid,  the  absolute  dulness  over  it 
shows  that  the  prominence  of  the  chest  is  not  caused  by  distended 
air-vesicles.  When  the  emphysema  is  extended  and  general, 
there  is  little  or  no  action  of  the  diaphragm,  and  the  comjihiint 
gives  rise  to  displacement  of  the  liver  or  heart ;  and  this  circum- 
stance, taken  in  connection  with  the  dilatation  of  the  chest  and  the 
dyspnoea,  brings  the  malady  into  a  category  of  affections  which 
will  be  examined  hereafter.  When  considering  this  group,  we 
shall  return  to  emphysema,  and  point  out  its  distinguishing  marks 
from  the  disease  for  which  it  is  most  likely  to  be  mistaken, — 
pneumothorax.  We  shall  only  here  add  that  the  affection  of  the 
heart,  the  torpid  displaced  liver,  and  the  presence  of  albumen 
in  the  urine,  in  emphysematous  patients,  may  call  away  attention 
from  the  primary  pulmonary  cause. 

An  effusion  of  air  may  take  place  into  the  areolar  tissue  uniting 
the  lobules.  There  are  no  jihysical  signs  peculiar  to  this  inter- 
lohulav  emphysema ;  they  are  exactly  the  same  as  those  furnished 
by  dilatation  of  the  air-cells,  except  that  a  dry  friction-sound  and 
a  large,  dry  crackling,  both  of  which  occur  occasionally  in  vesic- 
ular emphysema,  are  much  more  common.  Nor  are  there  any 
general  circumstances  specially  indicative  of  the  disease,  save  its 
suddenness,  and  the  external  emphysema  Avhich  follows.  The 
latter  is  detected  under  the  jaw,  or  at  the  base  of  the  neck,  and 
yields  a  peculiar  crepitation.  Yet  the  extravasation  of  air  into 
the  areolar  tissue  of  the  neck  is  not  a  constant  attendant  on  the 
extravasation  of  air  in  the  lung.  Besides,  the  possibility  of  a 
crepitating  swelling  in  the  neck  being  due  to  a  rupture  of  the 
bronchial  tube  or  of  the  larynx  must  be  borne  in  mind. 

The  rupture  of  the  air-cells  which  gives  rise  to  interlobular 
emphysema  is  brought  about  by  any  severe  effort,  by  violent 
coughing,  by  laughing,  or  by  the  throes  of  parturition.  It  has 
also  been  known  to  happen  in  the  course  of  pneumonia  or  of  pul- 
monary hemorrhage  and  to  have  caused  sudden  death.  Its  most 
frequent  association,  however,  is  with  hooping-cough. 

In  all  the  disorders  which  have  just  been  treated  of,  the  reso- 
nance on  percussion  has  been  dwelt  upon  as  a  most  valuable 


DISEASES    OP    THE    LUNGS.  311 

sign.  Before  proceeding  to  consider  the  diseases  in  wliich  dulness 
is  encountered,  a  few  words  may  here  find  their  place  on  a  morbid 
condition  in  which  clearness  rapidly  gives  way  to  dulness,  and 
dulness  changes  quickly  back  into  clearness.  As,  moreover,  the 
complaint  to  which  I  allude — collapse  of  the  lung — bears  a  close 
connection  with  bronchitis  and  emphysema,  and  has  been  made  to 
play  an  important  part  in  the  explanation  of  some  of  their  .symp- 
toms and  complications,  its  consideration  is  at  this  time  fitting. 

In  noticing  that  dulness  on  percussion  sometimes  appears  in 
the  course  of  a  case  of  capillary  bronchitis,  it  was  remarked  that 
this  does  not  of  necessity  show  that  the  inflammation  has  extended 
to  the  lobules ;  it  may  be  owing  to  the  air  in  the  lung  being  ex- 
hausted, and  the  pulmonary  tissue  collapsed.  Collapse  of  the 
lung  is  thus  a  return  of  the  organ  to  a  condition  akin  to  its  foetal 
state,  and  takes  place  throughout  a  large  portion  of  the  lungs, — 
diffused  collapse, — or  it  is  lobular.  Formerly  the  lobular  collapse 
was  invariably  mistaken  for  lobular  pneumonia.  Yet  the  aspect 
of  the  lung  in  many  instances  of  lobular  or  broncho-pneumonia 
had  attracted  the  attention  of  pathologists  long  before  Legendre 
and  Bailly  inflated  the  supposed  hepatized  lobules ;  it  was  then, 
indeed,  soon  found  that  an  accumulation  in  the  bronchial  tubes 
was  the  most  frequent  exciting  cause  of  that  condensation  of  the 
pulmonary  tissue  which  had  previously  been  regarded  as  a  sure 
indication  of  an  inflammation. 

These  accumulations  occasion  collapse  by  shutting  up  the  tube 
through  which  the  air  reaches  the  air- vesicles.  No  air  can  enter ; 
the  residual  air  is  gradually  exhausted,  and  the  disordered  portion 
of  lung  is  reduced  to  a  state  as  if  it  had  never  breathed.  But, 
although  in  the  majority  of  instances  this  condition  of  things  is 
brought  about  by  catarrhal  secretions  in  the  bronchial  tubes  which 
cannot  be  expectorated,  it  would  be  a  mistake  to  suppose  that 
these  are  always  present.  Any  want  of  power  to  fill  the  cells  of 
the  lung  with  air  may  lead  to  their  collapsing.  In  some  of  the 
typhoid  forms  of  acute  and  chronic  diseases,  in  the  pulmonary 
congestions  of  the  aged  and  enfeebled,  and  in  those  occurring 
just  prior  to  death,  large  portions  of  the  lung-tissue  may  collapse 
simply  from  inability  to  breathe  with  sufficient  force.  We  also 
meet  with  collapse  of  the  lung  in  hooping-cough. 

When  we  come  to  inquire  whether  the  diagnostic  signs  of  col- 


312  MEDICAL    DIAGNOSIS. 

lapse  of  tlie  lungs  are  so  clearly  defined  that  we  can  always  make 
out  tjie  state  of  the  pulmonary  tissue,  we  have  to  admit  that  our 
knowledge  of  the  pathological  phenomena  as  yet  exceeds  our 
power  to  recognize  them  in  the  living.  The  physical  signs  are 
not  satisfactory ;  the  symptoms  vary  with  the  conditions  pro- 
ducing the  disease.  There  is  dulness  as  in  the  other  forms  of 
condensation,  as  in  pneumonia,  as  in  pleurisy.  Neither  voice  nor 
respiration  is  characteristic.  The  most  usual  physical  sign  is  dul- 
ness on  percussion,  with  an  absence  of  all  respiration,  or  with  a 
blowing  sound,  which  is  faint  and  not  so  distinct  as  in  pneumo- 
nia. The  dulness  is  not  great,  may  be  changed  during  respira- 
tory percussion,  and  in  cases  dependent  upon  inspissated  mucus 
may  disappear  suddenly  when  the  obstructing  cause  is  removed. 
Yet  collapse  of  the  lung  is  at  times  a  state  of  long  duration. 
Great  stress  is  laid  by  some  on  the  signs  of  emphysema  which 
surround  the  dulness  of  the  condensed  tissue.  Should  a  pneu- 
monic process  aifect  the  collapsed  portion,  the  dulness  is  sta- 
tionary. 

After  collapse  the  breathing  becomes  very  difficult.  The  patient 
makes  intense  efforts  at  inspiration ;  owing  to  the  non-expansion 
of  the  lung  during  these  efforts,  the  ribs  move  inward  and  recede, 
instead  of  moving  outward  as  in  ordinary  breathing.  This  sign, 
the  suddenly-increased  dyspnoea,  and  the  appearance  of  dulness 
unaccompanied  by  marked  bronchial  breathing,  are,  in  a  case  of 
bronchitis,  the  most  trustworthy  indications  that  collapse  of  the 
lung-tissue  has  taken  place.  Yet  where  the  collapsed  lobules  are 
small  and  scattered  through  the  lung,  these  signs  are  not  all  pres- 
ent, and  the  diao;nosis  is  uncertain.  The  dulness  is  wanting ;  and 
the  peculiarity  in  inspiration  may  not  be  observed. 

When  collapse  affects  a  large  portion  of  lung,  it  much  resem- 
bles lobar  pneumonia  and  pleurisy,  from  both  of  which,  however, 
it  may  often  be  distinguished  by  the  phenomena  indicated,  and, 
still  more  positively,  by  the  history  and  the  absence  of  that  group 
of  symptoms  and  physical  signs  which  characterizes  inflammation 
of  the  lung  or  the  pleura.  How  nearly  it  resembles  broncho- 
pneumonia has  already  been  stated.  The  diminution  in  volume 
of  portions  of  the  chest,  the  shifting  character  of  the  physical 
signs,  the  speedy  re-entrance  of  air  into  parts  that  had  shown  signs 
of  condensation,  are  the  only  trustworthy  points  in  diagnosis. 


DISEASES   OF   THE    LUNGS.  313 

Diseases  in  which  Dulness  on  Percussion  occurs. 

The  diseases  of  the  hings  in  which  duhiess  on  percussion  is 
met  with  are  all  those  in  which  compression  or  consolidation  of 
tlie  pulmonary  tissue  takes  place.  EsjDecially  do  we  find  dulness, 
and  the  physical  signs  which  accompany  it,  in  the  phthises,  in 
pneumonia,  and  in  pleurisy. 

Phthisis. — Phthisis  presents  itself  in  a  chronic  and  in  an 
acute  form.  The  chronic  variety  is  by  far  the  most  frequent. 
It  is  essentially  "  the  consumption,"  which  is  such  a  scourge  to 
the  human  race.  In  by  far  the  greatest  number  of  instances  this 
consumption  is  linked  to  tubercular  disease.  And  although  we 
recognize  a  non-tubercular  form,  I  shall,  unless  otherwise  specified, 
use  the  term  phthisis  as  implying  tubercular  disease. 

Beginning  usually  with  a  short  and  insidious  cough,  with  a  feel- 
ing of  lassitude,  and  a  decline  in  general  health  ;  attended  at  times 
from  its  onset  with  a  pain  in  the  affected  lung  and  a  somewhat 
quickened  circulation ;  or  giving  the  first  indications  of  its  exist- 
ence by  the  occurrence  of  a  hemorrhage ;  or  developing  itself  after 
severe  bodily  or  mental  fatigue ;  or  traceable  to  some  neglected 
cold, — the  disease  becomes  fully  established,  with  symptoms  which 
hardly  need  a  detailed  description.  The  harassing  cough  by  day 
and  by  night;  the  impaired  appetite  and  disturbed  digestion;  the 
loss  of  blood  from  the  lungs ;  the  steadily-augmenting  debility ; 
the  short  breathing ;  the  exhausting  night-sweats ;  the  hectic 
fever;  the  deceptive  blush  which  this  imparts  to  the  cheek;  the 
increased  lustre  of  the  eye ;  the  singular  hopefulness ;  the  tem- 
porary improvements  ;  the  relapses ;  and  the  greater  vividness  of 
the  imagination,  so  strongly  contrasting  with  the  waning  frame, 
— are  phenomena  with  which  sad  experience  has  made  not  only 
every  physician,  but  many  a  fireside,  familiar. 

The  most  constant  of  all  these  symptoms  are  the  hemorrhage, 
the  cough,  and  the  emaciation.  The  cough  is  at  first  dry,  and 
followed  by  a  frothy  expectoration.  As  the  disease  advances, 
the  sputa  thicken.  They  become  greenish  in  color,  streaked  wuth 
yellow,  and  "  nummular,"  consisting  of  large  greenish  masses  of 
a  rounded  form,  or  sometimes  rounded  yet  with  jagged  edges, 
which  masses  do  not  sink  in  the  cup  containing  them,  but  float 
imperfectly  in  a  thin  serum.     This  expectoration  is,  however,  by 


314  MEDICAL   DIAGNOSIS. 

no  means  patliognomonie  of  the  niahuly  ;  it  is  oceasionally  en- 
countered" in  chronic  bronchitis.  In  the  hist  stages  of  consumj)- 
tion  the  sputa  are  often  homogeneous,  aud  liave  a  dirty-grayish, 
decidedly  puruknit  aspect.  Examined  microscopically,  they  show 
fi'agnients  of  the  structure  of  the  lung,  pus-cells,  exudation- 
globules,  and  those  peculiar  granular  bodies  which  were  at  one 
time,  but  are  nc»t  now,  regarded  as  characteristic  of  tubercle.  Yet 
the  only  a]>pearauces  in  the  sputum  at  all  distinctive  are  the  frag- 
ments of  the  pulmonary  hbrous  tissue.  Though  from  their  pres- 
ence we  are  sometimes  enabled  to  suspect  the  existence  of  con- 
sumption before  the  physical  signs  of  even  its  early  stages  are 
well  dehned,  we  can  never  be  quite  certain  that  the  breakage  of 
the  lung-texture  is  due  to  tubercular  disease.  An  excellent  way 
of  finding  the  lung-tissue  is  by  the  plan  of  Fenwick,* — to  liquefy 
the  sputum  by  means  of  pure  caustic  soda,  when  any  particles 
which  may  be  contained  in  it  fall  to  the  bottom  of  the  vessel, 
and  can  be  readily  removed  and  placed  under  the  microscope. 

The  whole  subject  of  the  minute  examination  of  the  sputum 
has  received  a  new  impetus  from  Koch's  discovery  of  the  micro- 
organism in  tuberculous  products, — the  bacillus  tuberculosis.  Its 
presence  bespeaks  tubercular  disease,  its  absence  is  an  almost  con- 
clusive argument  against  the  existence  of  this  affection.  Further, 
there  is  reason  to  believe  that  the  numbers  that  are  found  in  the 
sputum  bear  a  direct  relation  to  the  extent  and  gravity  of  the 
complaint ;  and  that  in  arrested  tubercle  they  become  very  few  or 
disappear.  In  lung  destruction  from  syphilis,  from  chronic  pneu- 
monia, in  cavities  from  bronchial  dilatation,  in  gangrene  of  the 
lung,  the  bacillus  is  not  observed  in  the  sputum.  But  not  finding 
the  bacilli  in  the  expectoration  is  not  as  valuable  evidence  as 
finding  them  ;  for  Koch  himself  failed  to  detect  them  in  a  certain 
number  of  cases  of  consumption. 

The  bacillus  tuberculosis  is  rod-shaped,  varies  in  knigth  from 
Y2^th  to  ^Jyo-th  of  an  inch,  is  absolutely  motionless,  produces 
spores,  and  is  blunt  at  both  ends.  But  to  distinguish  it  with  cer- 
tainty it  must  be  subjected  to  the  color  test.  This  is  now  generally 
done  by  a  modification  of  Koch's  method  suggested  by  Ehrlich,  and 
the  process  is  thus  followed  out.    A  small  drop  of  sputum  is  spread 

*  Medico-Chirurgical  Transactions,  vol,  xlix. 


DISEASES    OF    THE    LUNGS.  315 

very  thinly  over  the  surface  of  a  cover-glass,  a  second  cover-glass 
is  then  laid  upon  this,  and  the  two  are  pressed  together  and  then 
separated  by  sliding  one  over  the  other.  The  thin  layer  on  the  sur- 
face of  the  cover-glass  we  select  to  test  is  dried,  by  holding  it  over 
a  gas  or  alcohol  flame,  the  side  of  the  specimen  being  up.    The  dry 


Tubeicle-bacilli  in  sputum,  magnified  about  fifteen  hundred  dieimeters. — From  a  specimen 
prepared  by  Dr.  Lougstreth. 

sputum  is  now  stained  by  letting  the  cover-glass  lie  for  twenty-four 
hours  at  ordinary  temperature  in  a  saturated  solution  of  aniline  oil 
in  water,  made  by  adding  the  oil  drop  by  drop  to  distilled  water 
in  a  test-tube  until  the  mixture  becomes  turbid,  when  it  is  filtered 
and  a  few  drops  of  a  saturated  alcoholic  solution  of  fuchsin  are 
added.  At  the  end  of  this  time  all  the  component  parts  are 
stained,  including  the  bacilli.  The  cover-glass  is  now  immersed 
for  a  few  seconds  in  a  mixture  of  one  part  of  nitric  acid  to  three 
parts  of  water,  and  the  preparation  is  placed  in  alcohol  of  seventy 
per  cent,  until  no  more  color  is  given  oif :  the  color  disappears, 
except  that  of  the  bacilli,  which  are  red.  This  red  color  is  re- 
tained if  we  subsequently  color  the  background  blue  by  immersing 


316  MEDICAL    DIAGNOSIS. 

the  cov'cr-glass  for  a  few  minutes  in  a  two  per  cent,  watery  solution 
of  mcthyl-bluo  or  of  aniline  green.*  The  cover-glass  is  then 
washed  in  alcohol,  dried,  and  mounted  in  oil  or  in  Canada  balsam. 

In  rare  instances,  the  cough  remains  slight  throughout  the 
malady  ;  but  generally  it  is  a  very  distressing  feature  of  the 
complaint,  and  is  particularly  worrying  at  night.  Sometimes  its 
violent  paroxysms  bring  on  vomiting. 

Among  the  less  constant  symptoms  of  pulmonary  consumption 
are  a  troublesome  and  rebellious  diarrhoea,  chronic  laryngitis  and 
pharyngitis,  and  the  red  line  around  the  border  of  the  gum.  In 
some  persons  this  gingival  line  is  a  mere  streak ;  in  others  it  is 
more  than  a  line  in  breadth  ;  in  none  is  it  a  certain  indication. 
A  sion  which  has  a  much  more  definite  connection  with  tubercu- 
lar  disease  of  the  lungs  is  the  appearance  of  the  nails.  The  end 
of  the  finger  is  somewhat  clubbed  ;  the  nail  is  curved,  prominent 
in  the  centre,  depressed  at  the  sides,  its  surface  slightly  cracked, 
its  appearance  bluish.  This  peculiar  condition  of  the  nails  is  tol- 
erably constant,  and  is  sometimes  met  with  even  in  the  earlier 
stages  of  the  disease.  A  similar  nail  is,  however,  seen  in  chronic 
pleurisy  and  in  diseases  of  the  heart.  The  laryngeal  symptoms 
are  apt  to  be  a  very  distressing  complication,  and  mostly  end,  no 
matter  how  they  begin,  in  tubercular  laryngitis.  This,  and  the 
laryngoscopic  appearance  of  the  ulcers  which  attend  it,  have  been 
described  when  treating  of  lar}'ngeal  diseases. 

Another  significant  symptom  of  phthisis  is  the  heightened 
temperature  as  ascertained  by  the  thermometer.  Indeed,  the  tem- 
perature may  be  greatly  elevated  for  several  weeks  before  we  find 
physical  signs  indicative  of  the  deposition  of  tubercle,  or  of  an 
undoubted  increase  in  the  already  existing  deposition.  Fiu-ther- 
more,  the  rise  in  the  body  heat  closely  corresponds  to  the  activity 
of  the  deposition  of  tubercle.  If  the  temperature  be  decidedly 
and  permanently  elevated  throughout  the  day,  there  is  active  de- 
position. When  the  animal  heat  is  normal,  the  deposition  in  the 
lungs  has  ceased,  and  the  tubercular  process  is  arrested  or  retro- 
grading. 

But  these  statements,  as  I  know  from  repeatedly  examining  into 
the  matter,  do  not  aid  us  much  in  discriminating  lingering  lung 

*  Fraenkel,  Die  Bacterienkunde,  Berlin,  1887. 


DISEASES    OF    THE    LUNGS.    '  :317 

complications  in  febrile  states,  or  affections  intercurrent  in  tul)cr- 
cular  phthisis,  from  a  spread  of  tlie  disease,  or  certain  forms  of 
persistent  non-tnbercular  consolidations. 

The  morning  temperature  in  tubercular  phthisis  is  (jften  higher 
than  the  evening  temperature,  though  we  frequently  see  the  re- 
verse. In  the  last  weeks  or  last  days  of  the  disease  the  tempera- 
ture may  fall  greatly ;  and  C.  T.  Williams  *  tells  us  tliat  in  a 
large  number  of  chronic  cases  the  temperature  is  normal  or  sulj- 
normal,  sometimes  falling  to  between  93°  and  94°. 

The  thermometer  has  been  made  use  of  in  another  manner  in 
the  diagnosis  of  tubercular  consumption.  Peter  f  calls  attention 
to  the  advantage  of  local  thermometry.  A  surface  thermometer 
is  applied  firmly  in  front  of  the  chest  in  the  second  intercostal 
space,  and  if  the  temperature  be  higher  there  than  on  the  other 
side,  or  than  normal,  it  is  because  there  are  tubercles  underneath. 
In  beginning  tuberculosis  the  increased  local  heat  is  in  proportion 
to  the  extent  of  the  lesions.  In  health  the  temperature  of  the 
chest- walls  is  about  36°  Cent.  (96.8°  Fahr.) ;  it  may  rise  in 
tubercle  to  37°  Cent.,  or  more,  and  in  consumption  with  cheesy 
degeneration  still  higher,  surpassing  the  general  fever  heat  of  the 
body. 

The  symptoms  which  precede  a  fatal  termination  are  various. 
Patients  may  go  on  failing  for  years  ;  or  an  intercurrent  attack 
of  acute  tuberculosis,  of  pneumonia,  or  an  affection  of  the  brain 
or  of  the  intestines,  may  at  any  time  result  in  death. 

But  at  no  stage  of  the  disease  do  we  derive  as  exact  knowleds'e 
from  a  study  of  its  symptoms  as  we  do  from  a  study  of  its  phys- 
ical signs.  Before  explaining  these,  it  is  necessary  to  recall  briefly 
some  facts  connected  with  the  general  laws  governing  tubercle ; 
for  I  shall  in  these  descriptions,  as  already  stated,  adhere  to  the 
idea  of  the  tubercular  nature  of  phthisis,  and  use  the  terms  as 
synonymes,  taking  subsequently  special  cognizance  of  other  forms, 
especially  of  the  inflammatory. 

Tubercle  is  an  unorganized  substance,  the  deposits  of  which  are 
at  first  isolated,  then  accumulate.  The  tendency  of  tubercular 
matter  is  to  soften  and  destroy  the  textures  among  which  it  is 


*  The  Doctor;  quoted  in  Half- Yearly  Compendium,  July,  1875. 
f  Clinique  Medicale,  tome  ii.,  1879. 


318  ■  MEDICAL   DIAGNOSIS. 

infiltrated.  It  may  undergo,  at  any  period  in  its  course,  a  retro- 
gressive development,  by  shrivelling  up,  or  by  passing  into  a  cal- 
careous state.  M'hen  situated  in  the  lungs,  it  seeks  the  apices  by 
preference  ;  it  is  rarely  limited  to  one  lung,  although  one  lung  is 
usually  the  most  diseased,  and  often  at  the  beginning  of  the  malady 
is  alone  affected.  It  is  not  merely  a  local  complaint,  but  stands  in 
connection  with  a  peculiar,  tainted  state  of  the  constitution  :  hence 
the  symptoms  of  phthisis  are  not  solely  the  expressions  of  the 
■condition  of  the  lungs. 

These  patliological  facts  are  all  of  the  greatest  importance. 
They  tell  us  where  to  seek  for  the  earliest  indications  of  a  deposit. 
Thev  explain  to  us  its  signs.  They  teach  us  to  look  further  than 
the  lungs,  and  prepare  us  for  finding  lesions  in  other  organs. 

In  accordance  with  the  laws  affecting  tubercular  depositions,  we 
have  three  stages  of  phthisis,  which  run,  however,  by  almost  im- 
perceptible degrees  into  one  another.     They  are  : 

1.  Incipient  stage,  or  beginning  deposition; 

2.  ]\Iore  complete  deposition,  occasioning  consolidation  ; 

3.  Stage  of  softening  and  of  the  formation  of  cavities. 

1.  A  few  scattered  tubercles  do  not  change  the  normal  percus- 
sion resonance  ;  nor  do  they  appreciably  alter  the  natural  breath- 
sounds.  But  as  soon  as  the  deposit  is  sufficient  to  impair  the 
elasticity  of  the  lung-tissue  or  to  increase  its  density,  a  relative 
loss  of  clearness  on  percussion  on  one  side,  and  modifications 
of  the  vesicular  murmur,  such  as  feeble  or  jerking  inspiration, 
or  a  prolonged  expiration,  may  be  ascertained.  Tlie  dulness  is 
readily  detected  by  percussing  the  patient  with  his  mouth  open 
and  during  a  fixed  expiration,  or  the  difference  between  the  two 
sides  becomes  very  manifest  during  held  inspiration  ;  in  other 
words,  respiratory  percussion  will  aid  us.  To  find  the  dulness  at 
the  upjier  part  of  the  chest  posteriorly,  the  position  recommended 
by  Corson,*  of  crossing  the  arms  and  clasping  the  shoulders,  is 
very  advantageous.  In  a  certain  number  of  cases,  with  the  slight 
dulness  on  percussion  and  the  changed  breathing  is  associated  a 
blowing  sound  in  the  subclavian  or  in  the  pulmonary  artery.  A 
murmur  is,  indeed,  at  times  present  in  the  pulmonary  artery  long 
before  any  other  physical  indication  of  tubercle  is  discernible. 


*  New  York  Journal  of  Medicine,  March,  1859. 


DISEASES   OF   THE   LUNGS. 


319 


All  these  physical  signs  may  be  accoiiipanicd  by  rales  of  vavions 
kinds.  What  makes  them  significant  is,  that  they  occur  at  the 
upper  portion  of  the  lung,  whether  anteriorly  or  posteriorly. 
If,  therefore,  any  modification  of  the  vesicular  murmur,  or  any 
adventitious  sound  limited  to  the  apex,  exist ;  if  there  be  a  slight 


Tig.  25. 


Slight  percussion  dulness. 

Feeble  or  harsh   respira- 
tion  


Prolonged  expiration. 


Exaggerated  respiration- 


Beginning  infiltration  ;  masses  of  tubercle  have  accumulated, 
but  the  intervening  lung-tissue  is  still  healthy. 


dulness  on  percussion  above  or  under  the  clavicle,  or  in  the  supra- 
spinous fossa ;  if  this  coincide  with  flattening  of  the  anterior  sur- 
face of  the  chest,  especially  on  one  side,  with  defective  expansion 
of  the  thorax  and  shortness  of  breath,  with  a  cough  and  falling 
off  in  general  health, — the  diagnosis  of  beginning  tubercular 
disease  is  almost  positive. 

2.  As  the  infiltration  advances,  the  signs  become  more  decidedly 
those  of  consolidation.  Greater  dulness  on  percussion  at  the  upper 
portion  of  one  or  of  both  lungs,  scarcely  influenced  by  respiratory 
percussion ;  more  resistance  to  the  percussing  finger  ;  stronger 
vocal  resonance ;  a  sinking  in  of  the  side  most  affected,  and  often 
soreness  to  the  touch  over  the  diseased  part;  a  very  harsh  mur- 
mur ;  or,  when  the  infiltration  surrounds  the  bronchial  tubes,  a 


320 


MEDICAL    DIAGNOSIS. 


distinct  l)lowing  rc^^jMration, — are  all  presont  in  varving  degree, 
and  all  denote  consolidation.  And  chronic  consolidation  at  the 
apex  has,  in  the  large  majority  of  instances,  bnt  one  interpreta- 
tion ;  phthisis.  In  the  second  stage,  as  well  as  in  the  first,  we 
often  meet  with  superadded  signs  of  bronchitis  which  occasionally 
mask  the  resj)iratory  sounds,  and  Avith  friction-sounds  from  local 
pleurisies,  or  with  tine  crackling. 

3.  The  diseased  organ  now  passes  into  a  state  of  softening,  or 
rather  some  portions  of  the  lung  begin  to  soften,  while  others 
remain  indurated,  and  in  yet  others  fresh  infdtration  takes  place. 

Fig.  26. 


Cavernosa 
respiration. 

Gurgling. 
Cavernous 


Cavities  of  various  sizes. 


]\foist  crackling  or  persistent  moist  rales  indicate  that  softening 
has  begun.  The  broken-down  material  may  be  expectorated,  and 
the  malady  for  a  time  be  stayed ;  but  such  is  not  often  the  case. 
The  area  of  the  softened  mass  widens ;  cavities  form  ;  and  in 
addition  to  the  moist  rales,  to  the  physical  phenomena  of  the 
second  stage,  and  to  the  increasing  debility,  night-sweats,  and 
hectic,  the  sio-ns  indicative  of  a  cavitv  are  noticed.  What  these 
are,  may  be  learned  from  the  above  engraving.  Prominent 
among  them  are  the  cavernous  voice,  especially  in  whispering. 


DISEASES    OF    THE    LUNGS.  321 

and  the  hollow  breathing.  Bnt  the  hollow,  cavernous  respira- 
tion may  be  caught  only  in  expiration,  or  it  may  be  temporarily 
superseded  by  very  large  bubbling  sounds, — gurgling.  Again, 
over  small  or  over  deep-seated  cavities  none  of  these  sounds  may 
be  perceived ;  and,  in  truth,  even  when  they  exist,  their  limita- 
tion to  a  particular  locality  is  an  element  in  the  diagnosis  of  a 
cavity  almost  as  important  as  their  presence. 

The  results  of  percussion  over  an  excavation  are  not  always  the 
same.  They  depend  much  on  the  thickness  and  the  state  of  the 
walls  of  the  cavity.  If  dense,  percussion  yields  a  dull  sound  ;  if 
thin,  a  tympanitic,  or  its  varieties,  a  cracked-pot  or  a  metallic  sound. 
If  only  a  certain  amount  of  indurated  tissue  intervene  between  the 
cavity  and  the  surface  of  the  chest,  a  singular  sound,  a  mixture  of 
dull  and  tympanitic,  is  produced.  If  healthy  lung-tissue  form  the 
walls  of  the  excavation,  the  sound  is  clear,  or  nearly  so.  More- 
over, in  all  cases  the  pitch  and,  to  some  extent,  the  character  of  the 
sound  are  changed  by  percussing  over  the  cavity  while  the  mouth 
is  kept  open.  When  it  is  shut,  the  sound  elicited  is  of  lower 
pitch.  On  respiratory  percussion,  the  previously  tympanitic  or 
mixed  sound  becomes  dull.  Another  sign  by  which  we  may  judge 
of  the  existence  of  a  cavity  at  the  upper  part  of  the  lung,  is  the 
extraordinary  clearness  with  which  the  heart-sounds  are  heard  at 
that  point,  or  a  waving  impulse  in  the  second  intercostal  space. 

Such,  then,  are  the  physical  signs  which  indicate  the  varied 
structural  conditions  of  the  lung  in  the  three  stages  of  phthisis. 
With  these  signs  are  associated,  as  symptoms,  cough,  increasing 
quickness  of  breathing,  progressive  debility,  hectic  fever,  digestive 
disorders,  and  emaciation, — symptoms  the  occurrence  and  severity 
of  which  mark  also,  though  not  very  accurately,  the  periods  of 
the  malady.  Irrespective  of  these  three  stages,  some  have  ad- 
mitted a  stage  preceding  the  deposition  of  the  tubercles.  That 
such  a  pretubercular  stage  exists  is  not  improbable ;  that  the 
ability  to  recognize  it  would  be  one  of  the  most  important  and 
valuable  gifts  to  practical  medicine,  is  undoubted ;  but  whether 
it  be  recognizable,  is  another  matter.  It  does  not  seem  to  me  that 
the  advocates  of  the  possibility  of  detecting  phthisis  at  this  stage 
have  clearly  proved  their  point.  On  the  one  hand,  they  lay  claim 
to  signs,  such  as  diminished  expansion  of  the  chest,  decreased  vital 
capacity,  a  respiratory  murmur,  feeble  and  remaining  feeble  on 

21 


322  MEDICAL   DIAGNOSIS. 

forced  brcathino;,  h.Tmoptysis,  even  slight  dulness  on  percussion, 
— a  combination  which  we  are  accustomed  to  regard  as  evidence 
that  tubercle  already  exists ;  on  the  other  hand,  they  assert  that  de- 
fects of  temperature,  lessened  muscular  power,  impro])er  assimila- 
tion, emaciation,  sore  throat,  and  slight,  dry  cough,  are  prodromic 
symptoms.  Yet  all  of  these  may  be  associated  with  a  temporary 
derangement  of  health,  and  all  of  these  are  far  more  frequently 
so  associated  than  with  threatening  consumption.  And  to  say 
that  they  become  of  value  only  when  coexisting  with  the  physical 
signs  alluded  to  is  but  to  say  that  they  are  the  clinical  phenomena 
which,  thus  grouped,  we  are  in  the  habit  of  accepting  as  proof  of 
the  first  stage  of  the  disease.  But,  without  entering  further  into 
this  question,  it  may  be  stated  that  the  deposition  can  generally 
be  detected  at  a  very  early  period  by  careful  cxploi-ations  of  the 
chest,  by  the  history  of  the  case,  and  by  examining  the  sputum 
for  bacilli. 

An  interesting  contribution  to  our  knowledge  has  recently  been 
made  by  Fowler,*  which  Avill  help  us  in  the  clearer  recognition 
of  the  malady.  It  consists  in  watching  the  extension  of  the 
lesions  in  their  "  line  of  march,"  which  is  found  to  take  place  in 
a  regular  manner.  The  primary  lesion  is  not  often  in  the  ex- 
treme apex  of  the  lung,  but  has  its  site  from  an  inch  to  an  inch 
and  a  half  below  the  summit  of  the  lung,  and  rather  nearer  to 
the  posterior  and  external  borders.  Lesions  in  this  position  tend 
to  spread  backwards,  and  thus  is  explained  why  we  may  have  the 
physical  signs  of  deposit  marked  in  the  suj)ra-spinous  fossa  while 
they  are  still  uncertain  in  front.  Another  site  of  primary  affection 
is  at  a  spot  corresponding  on  the  chest-wall  with  the  first  and 
second  interspaces  below  the  outer  third  of  the  clavicle.  The 
lower  portion  of  the  lung  is  usually  involved  before  the  apex  of 
the  opposite  lung. 

Let  us  now  look  at  the  disorders  with  which  phthisis,  in  its 
various  stages,  is  likely  to  be  confounded.  They  are,  to  speak 
of  thoracic  affections  only  : 

Chronic  Bronchitis  ; 

Cpironic  Pneumonic  Consolidation  ; 

Chronic  Pleurisy; 

*  Tlic  Localiziition  of  the  Lesions  of  Phthisis,  London,  1888. 


DISEASES   OF   THE   I.UNGS.  323 

PULMONAEY    CanCER ; 

Syphilitic  Disease  of  the  Lungs; 

Bronchial  Dilatation; 

Pulmonary  Abscess  ; 

Pulmonary  Gangrene. 

Chronic  Bronchitis. — The  first  stage  of  consumption  is  particu- 
larly prone  to  be  mistaken  for  chronic  bronchitis.  Nor  is  the 
diagnosis  always  easy.  Distinct  tlulness  on  percussion  at  the 
apex  is  of  much  aid  in  discrimination,  especially  if  it  be  on  the 
left  side.  On  the  right  side  it  is  of  far  less  value,  unless  marked 
alterations  of  the  vesicular  murmur  correspond  to  it.  When  the 
dulness  is  not  discernible,  we  have  to  depend,  in  our  efforts  at  a 
separation  of  the  two  diseases,  on  tlie  history  of  the  case,  the 
limitation  of  the  physical  signs  to  the  apex,  and  the  proofs  of 
increased  activity  of  the  surrounding  lung.  Cough  and  expecto- 
ration are  common  to  both  affections.  But  they  are  associated, 
in  chronic  bronchitis,  with  physical  signs  more  or  less  diffused 
through  both  lungs,  and  unaccompanied  by  much  constitutional 
disturbance ;  while  from  the  onset  of  phthisis  the  falling  off  in 
general  health  is  out  of  proportion  to  the  local  lesions.  Yet 
until  crackling  or  some  dulness  on  percussion  is  perceived,  the 
diagnosis  remains  uncertain.  These  indications  of  beo-inning; 
consolidation  settle  the  diagnosis  against  bronchitis.  And  this 
view  of  a  case  will  be  strengthened  if  hemorrhage  have  occurred, 
and  if  the  phenomena  be  present  in  a  person  born  of  a  family  in 
which  consumption  is  hereditary. 

Where  the  deposition  is  at  all  extensive,  an  erroneous  diagnosis 
of  bronchitis  is  with  ordinary  care  impossible,  unless,  as  is  always 
highly  improbable,  phthisis  should  be  complicated  with  emphy- 
sema, or  the  tubercles  be  quiescent  and  so  diffused  as  not  to  im- 
pair the  resonance  on  percussion.  Under  the  latter  circumstances 
especially,  the  occasional  tympanitic  character  of  the  sound  over 
the  seat  of  the  tubercular  deposition  is  liable  to  be  misconstrued 
into  increased  clearness  on  percussion,  and  into  a  disproval  of  the 
existence  of  phthisis.  When  tubercle  and  emphysema  coexist, 
the  percussion  note  may  really  be  pulmonary  and  like  that  of 
healthy  lung.  We  should  then  have  to  judge  of  the  one  disease 
following  the  other  mainly  by  the  respiratory  sound,  which  be- 
comes much  feebler ;   generally,  too,  the  dyspnoea  is  increased. 


324  MEDICAL    DIAGNOSIS. 

The  thermometer,  as  Ringer  suggests,  by  showing  a  higher  tem- 
perature .than  in  pure  em})hysenia,  may  assist  us.  But  tlie  most 
certain  sign  would  be  the  baeilli  in  the  sputum. 

A  diffieult  diagnosis  may  be  at  times  the  distinction  between 
chronic  bronchitis  and  the  phthisis  of  old  people:  This,  indeed, 
often  happens  in  a  latent  form,  and  is  very  slow  in  its  develop- 
ment. Besides  the  microscopic  examination  of  the  sputum,  aus- 
cultation alone  is  of  much  value,  since  the  chest  remains  resonant 
on  percussion,  owing  to  the  dwindling  of  the  muscles  of  the  tho- 
rax, the  ossification  of  the  ribs,  and  the  rarefaction  of  the  lungs. 

In  the  stage  in  which  the  signs  of  consolidation  become  well 
defined,  phthisis  may  be  mistaken  for  any  of  those  conditions 
which  occasion  the  physical  signs  indicative  of  greater  density 
of  the  lung-tissue,  and  which  are  accompanied  by  cough  and  by 
loss  of  flesh.  Such  are  particularly  pneumonic  consolidation, 
pleuritic  effusion,  and  cancerous  deposits. 

Chronic  Pneumonic  Consolidalion. — Chronic  pneumonic  consol- 
idation, or,  as  the  affection  is  commonly  called,  chronic  pneumonia, 
gives  rise  to  many  manifestations  which  simulate  consumption. 
These  are  cough,  emaciation,  and  the  local  signs  of  chronic  con- 
densation,— increased  voice  and  fremitus,  sinking  in  of  the  chest- 
wall,  feeble  inspiration  and  prolonged  expiration,  or  a  fully-devel- 
oped bronchial  respiration.  But  in  pneumonic  consolidation  the 
history  usuallv  points  to  an  antecedent  acute  affection ;  the  health 
is  not  so  much  impaired  ;  there  has  been  no  hemorrhage,  although, 
owing  to  intervening  acute  bronchitis,  the  sputa  at  times  may  have 
been  streaked  with  blood  ;  and  the  dulness  on  percussion  and  the 
other  physical  signs  of  consolidation  are,  for  the  most  part,  per- 
ceived over  the  lower  lobe  of  one  lung. 

This  position  of  the  physical  signs  is  of  great  importance.  Yet 
there  are  two  sources  of  fallacy  which  may  arise.  On  the  one 
hand,  tubercles  may,  by  way  of  exception,  be  seated  in  the  lower 
lobe ;  on  the  other,  chronic  pneumonic  induration  may  affect  the 
apex.  When  an  infiltration  of  tubercle  takes  place  in  the  lower 
lobe,  its  distinction  from  chronic  pneumonic  condensation  is  very 
difficult.  Our  only  guides  are  the  evidence  furnished  by  the 
graver  constitutional  symptoms  of  phthisis,  and  attention  to  that 
pathological  law  which  teaches  that  consumption  is  not  met  with 
in  an  advanced  state  in  one  lung  alone:  hence  we  must  watch  care- 


DISEASES   OF   THE   LUNGS.  325 

fully  the  other  lung.  So  long  as  it  is  not  involved,  there  is  reason 
to  conclude  against  the  tubercular  character  of  the  deposit.  In 
like  manner,  by  ascertaining  the  one-sidedness  of  the  disease,  and 
by  noting  the  want  of  those  serious  symptoms  which  go  hand  in 
hand  with  the  physical  signs  of  tubercular  phthisis,  we  may  deter- 
mine the  real  nature  of  the  case  when  an  inflammation  of  the  upper 
lobe  has  resulted  in  its  persistent  induration.  I  adduce  a  few  in- 
stances, by  way  of  illustration  : 

A  gentleman  was  under  my  care  for  years,  in  whom,  after 
pulmonary  inflammation,  signs  of  condensation  remained  in  the 
upper  part  of  the  right  lung.  He  did  not  suffer  at  all,  except 
from  attacks  of  acute  bronchitis,  to  which  he  was  very  liable. 
Daring  these  he  lost  flesh ;  but  when  they  passed  off  he  rapidly 
regained  it.  He  had  a  chronic  cough,  but  it  was  very  slight. 
After  the  lapse  of  a  number  of  years  I  lost  sight  of  him. 

In  another  case,  with  a  similar  history,  I  found  dulness  on  per- 
cussion, prolonged  expiration,  and  a  friction-sound  limited  to  the 
apex  of  the  right  lung.  Tliere  had  been  a  continuous  cough,  but 
very  little  constitutional  disturbance,  and  no  hemorrhage.  The 
abnormal  signs  lasted  for  a  year,  and  then  almost  disappeared 
under  a  succession  of  blisters,  and  the  cough  ceased. 

In  both  cases  the  signs  were  confined  to  the  summit  of  one 
lung.  I  had  some  time  since  under  observation  a  patient  affected 
much  in  the  same  manner,  a  man  seventy-five  years  of  age,  in 
whom  the  dulness  at  the  right  apex  had  for  years  remained  sta- 
tionary. I  might  cite  further  examples  ;  but  these  are  sufiicient 
to  justify  the  conclusions  that  can  be  drawn  from  the  facts  men- 
tioned. 

But  to  return  to  the  points  of  difference  between  chronic  indu- 
ration of  the  lung  and  tubercular  phthisis.  They  may  be  thus 
summed  up  :  when  the  signs  of  consolidation,  whether  existing  at 
the  upper  part  of  the  lung  or  not,  are  out  of  proportion  to  the 
general  symptoms,  there  is  reason  to  believe  that  they  are  not  the 
result  of  tubercular  infiltration.  The  non-occurrence  of  hemor- 
rhage would  tend  to  strengthen  such  an  inference.  But  the  most 
important  information  is  drawn  from  watching  whether  the  phys- 
ical signs  undergo  changes  indicative  of  a  deposit  in  the  hitherto 
healthy  portions  of  the  pulmonary  texture.  And  it  must  be  con- 
fessed that  minute  and  accurate  examinations   having  reference 


326  MEDICAL   DIAGNOSIS. 

directly  to  this  point  are  sometimes  the  only  means  through 
which  a  positive  opinion  can  be  reached.  To  tiie  presence  or  ab- 
sence of  the  bacillus  tuberculosis  in  the  sputum  weitiht  may  also 
be  attached.  But  the  presence  is  of  far  more  value  in  diagnosis 
than  the  absence. 

A  great  and  complicating  difficulty  in  the  differential  diagnosis 
remains  to  be  mentioned.  It  grows  out  of  the  circumstance  that 
tubercular  disease  may  be  developed  in  a  lung  which  is  in  a  state 
of  chronic  induration.  Whatever  the  explanation,  the  fact  cannot 
be  disputed  that  we  find  persons  who  are  without  a  trace  of  pul- 
monary disorder,  seized  with  an  inflammation  of  the  lung,  which 
is  followed  by  persistent  consolidation,  and  in  the  course  of  time 
by  undoubted  tubercular  phthisis.  Indeed,  many  of  the  reported 
cases  of  tubercle  affecting  primarily  the  lower  lobe  of  the  lung 
are,  in  reality,  cases  of  tubercle  following  chronic  pneumonic 
consolidation.  The  history  is  usually  as  follows.  A  person  in  all 
respects  healthy  is  attacked  with  an  acute  pulmonary  affection. 
He  recovers  from  it,  but  with  a  trifling  cough,  with  a  persistent 
dulness  on  percussion,  and  with  a  feeble  respiration,  heard  over 
one  of  his  lungs.  He  continues  ailing,  yet  is  not  positively  ill, 
when,  without  any  apparent  cause,  after  a  time  varying  from  a 
few  months  to  years,  the  pulse  becomes  frequent,  his  cough  in- 
creases, the  expectoration  augments  greatly  in  quantity  and  be- 
comes decidedly  purulent,  the  temperature  rises,  and  he  emaciates 
rapidly.  Profuse  night-sweats  occur  ;  and  the  physical  signs, 
which  have  been  stationary  for  a  long  time,  now  begin  to  change. 
The  dulness  extends ;  and,  instead  of  the  enfeebled  respiration,  a 
harsher,  blowing  respiration  is  perceived  over  the  afitected  part, 
and  moist  crackling  and  the  signs  of  a  cavity  follow.  Doubt 
may  still  exist  as  to  the  nature  of  the  malady,  but  the  advance 
of  the  disease  clears  up  the  doubt.  True  to  the  laws  of  tubercle, 
a  deposit  takes  place  in  the  lung  previously  sound,  and  not  at  the 
lower  portion,  but  at  its  apex. 

Hemorrhage  may  or  may  not  occur.  In  the  patient  from  whose 
case  the  above  description  is  drawn,  it  did  not  happen  ;  and  in 
others,  too,  it  was  wanting.  Its  presence  is,  therefore,  strongly  in 
favor  of  the  fact  that  tubercles  have  been  developed ;  its  absence 
does  not  positively  prove  the  contrary. 

I  leave  these  remarks  as  they  were  originally  written.     Of  late 


DISEASES    OF    THE    LUNGS.  327 

years  a  school  of  pathologists,  witli  Nicmeycr  at  their  head,  have 
endeavored  to  re-establish  the  old  doctrine  that  consumption  of 
the  lung  and  the  formation  of  cavities  are  most  frequently  the 
result  of  chronic  inflammation.  According  to  this  view,  cases  such 
as  those  just  discussed  belong  to  the  great  group  of  phthisis  in 
which  the  pneumonic  process  terminates  in  caseous  degeneration 
and  destruction  of  tissue.  This  group,  pneumoniG  phthids,  held 
to  be  the  most  common  form  of  consumption,  presents  somewhat 
different  traits  according  to  the  rapidity  of  its  development.  It 
differs  from  the  true  tuberculous  consumption,  due  to  a  tubercular 
deposit,  in  this  :  the  latter  has  no  precursory  catarrh  or  catarrhal 
pneumonia,  the  marked  fever  and  the  emaciation  are  not  deferred 
until  the  expectoration  becomes  profuse  and  purulent,  the  patient 
wastes,  and  then  begins  to  cough  and  expectorate.  At  first  the 
physical  examination  of  the  chest  may  give  negative  results,  and 
even  at  a  later  period  the  solidification  is  not  so  extensive  as  in  the 
first  form  of  consumption, — that  following  inflammation.  In  this 
there  is  more  uniform  infiltration,  although  the  disease  is  more 
localized  ;  it  is  slow  in  its  progress ;  shows  more  or  less  increased 
temperature,  and  a  tendency,  under  treatment,  toward  contraction 
and  induration  of  the  affected  part  of  the  lung,  which  may  result  in 
a  cure.  Yet  one  of  the  dangers  is  that  it  may  become  tuberculous  ; 
though  even  then  the  morbid  process  appearing  at  an  advanced 
stage  of  the  lung  destruction  has  little  to  do  with  the  disorganiza- 
tion of  the  lungs.  How  the  tubercle  arises  is  not  certain,  but  it 
has  some  connection  with  the  cheesy  changes  of  the  products  of 
the  inflammation.  It  may  be  that  in  them  the  bacilli  find  a  ready 
nidus. 

Now,  the  remarks  made  will  apply  almost  equally  where  the 
original  seizure  was  an  ordinary  croupous  pneumonia,  or  a  catarrhal 
pneumonia.  In  both  we  have  the  signs  of  consolidation  remain- 
ing ;  in  both  the  same  questions  of  diagnosis  may  arise,  as  to 
whether  the  lung  is  undergoing  cheesy  degeneration,  and  as  to  the 
formation  of  tubercle.  Yet  there  are  some  points  which  the 
chronic  consolidation  that  attends  a  chronic  catarrhal  pneumonia 
exhibits,  that  I  shall  here  refer  to.  In  the  first  place,  the  history 
of  a  preceding  acute  catarrhal  attack  is  clear,  or  there  have  been 
a  series  of  attacks,  after  one  of  which  the  lung  was  left  solid,  and 
since  which  the  patient  has  remained  delicate,  prone  to  take  cold, 


328  MEDICAL    DIAGNOSIS. 

and  is  easily  put  out  of  breath.  Now,  he  may  Qome  under  our 
observation  in  the  midst  of  one  of  tliese  broneho-pneumonic  seiz- 
ures, and  we  may  wateh  him  for  five  or  six  months  witii  the  signs 
of  consolidation  over  portion  of  one  lung',  whether  at  base  or 
apex,  or  with  aft'ected  points,  often  symmetrical,  in  both ;  further, 
there  are  night-sweats,  fever  with  decided  evening  exacerbation, 
diarrhoea.  Gradually  these  urgent  symptoms  yield  ;  he  gets  about, 
but  a  spot  or  spots  of  consolidation  in  one  or  both  lungs  do  not 
pass  away  for  many  months ;  or  the  chronic  catarrhal  pneumonia 
may  remain  as  such  or  terminate  in  caseous  degeneration  in  the 
manner  described, — may,  in  other  words,  pass  into  pneumonic 
phthisis,  which,  I  think,  means  really  tubercle.*  When  this 
happens,  great  variation  between  morning  and  evening  tempera- 
ture, simulating  a  malarial  fever,  increasing  cough  and  dyspnoea, 
marked  sweats,  decided  emaciation,  announce  the  event;  while 
the  physical  signs  show  extending  dulness,  crackling  and  tine 
moist  rales,  over  the  affected  spots,  or  in  parts  not  previously 
diseased,  and  ultimately  cavities.  At  all  stages  repeated  exami- 
nations of  the  sputum  for  bacilli  are  of  decisive  value. 

Chronic  Pleurisy. — A  persistent  cough  attended  with  emaciation 
and  with  dulness  on  percussion  is  common  to  chronic  pleurisy  and 
to  phthisis,  and  is  a  cause  of  many  errors.  But  the  seat  of  the 
dulness  at  the  lower  part  of  the  thorax ;  its  much  more  absolute 
character  ;  the  almost  entire  cessation  of  all  breath-sound ;  the 
diminished  or  absent  vibration  of  the  chest-Avalls  when  the  patient 
speaks ;  the  dilatation  of  the  affected  side, — are  in  striking  con- 
trast Avith  signs  most  manifest  at  the  apex,  with  the  distinctly- 
prolonged  expiration,  with  the  rales  and  the  evidences  of  begin- 
ning softening.  Nor  are  the  symptoms  of  a  pleuritic  effusion  as 
grave  as  those  produced  Ijy  phthisis.  Even  where  the  fluid  filling 
the  chest  is  pus,  we  do  not  find  hectic  fever  so  intense,  emaciation 
so  great,  or  night-sweats  so  constant  and  exhausting ;  and  the 
patient  coughs  less,  and  never  spits  up  blood.  In  those  cases  of 
chronic  pleurisy  in  which  the  side,  instead  of  being  dilated,  is 
retracted,  the  diagnosis  is  more  difficult.  Attention  to  the  seat 
of  dulness  being  at  the  lower  part  of  the  chest,  to  the  diminished 
respiration,  voice,  and  fremitus,  and  to  the  shrinking  affecting  only 

*  See  a  paper  of  mine,  Philu.  Med.  Times,  June  19,  1880. 


DISEASES   OF   THE   LUNGS.  329 

one  side  of  the  thorax,  will,  however,  serve  as  the  foundation  for 
a  correct  conclusion. 

Tubercle  may  complicate  pleuritic  effusions.  We  suspect  this 
by  the  occurrence  of  hemorrhage,  and  by  the  marked  emaciation 
and  hectic.  We  can  only  be  sure  of  it  by  finding  signs  of  deposit 
on  the  non-affected  side,  which  deposit,  in  accordance  with  the 
custom  of  tubercular  disease,  will  take  place  first  at  the  apex,  and 
by  bacilli  in  the  sputum.  Chronic  double  pleurisy  is  very  apt  to 
be  associated  with  a  tubercular  affection  of  the  lungs. 

Pulmonary  Cancer. — Cancer  of  the  lung  has  many  symptoms 
which  it  shares  with  tubercle.  Cough,  night-sweats,  hemorrhage, 
gradual  wasting,  belong  to  both  diseases,  as  do  the  signs  of  pulmo- 
nary consolidation.  But  cancerous  formations  are  usually  limited 
to  one  lung.  Only  one  side  of  the  chest  is,  therefore,  flattened 
or  distended.  Over  the  cancerous  lung  the  percussion  dulness  is 
great.  There  is  either  loud,  blowing  respiration,  or,  if  the  mass 
have  compressed  or  obliterated  a  bronchus,  enfeebled  or  absent 
breathing.  We  find  no  rales ;  but  all  the  signs  of  consolidation 
are  more  perfect  than  in  tubercle.  Owing  to  a  cancerous  deposit 
in  the  mediastinum,  the  dulness  at  times  extends  beyond  the  me- 
dian line.  Cancer  in  the  lung  may  soften ;  yet  the  signs  of  soft- 
ening are  rarely  as  manifest  as  they  are  in  tubercle.  The  sputa 
are  purulent,  or  like  currant-jelly.  Further,  a  cancerous  tint  of 
the  skin  may  be  present ;  and,  again,  cancerous  tumors  in  other 
parts  of  the  body  become  next  to  absolute  evidence  in  favor  of  a 
deposit  in  the  lung  being  cancerous,  since,  with  very  rare  excep- 
tions, cancer  and  tubercle  do  not  coexist.  The  character  of  the 
pain  must  also  be  taken  into  account.  In  tubercle,  it  is  transitory 
and  shifting  ;  in  cancer,  it  is  much  more  constant,  and  much  more 
severe.* 

*  Compare,  ob  this  subject,  the  cases  collected  by  Bennett  in  his  Clinical 
Lectures  ;  by  Hughes,  Guy's  Hospital  Keports,  1st  Series,  vol.  ii.  ;  by  Stokes, 
Dubl.  Journ.  of  Med.,  vol.  xxi.  ;  by  James  Risdon  Bennett,  Intra-Thoracic 
Growths,  London,  1872;  by  Meissner,  Schmidt's  Jahrbiicher,  1879,  No.  4;  by 
Suckling,  Lancet,  London,  1884,  ii.  ;  by  Dyce  Duckworth,  Brit.  Med.  Journ., 
London,  1885,  i.  ;  by  A.  T.  H.  Waters,  Brit.  Med.  Journ.,  1886,  i. ;  by  Gold- 
schmid,  Cor.-Blatt  f.  Schweiz.  Aerzte,  Basel,  1886,  xvi. ;  by  M.  A.  Boyd, 
Transact.  Acad,  of  Med.,  Dublin,  Ii-eland,  1886,  iv. ;  by  P.  Menetrier,  Progres 
Med.,  Paris,  1887,  2.  s.,  v.  ;  by  A.  T.  H.  Waters,  Contrib.  to  Clin,  and  Praet. 
Med.,  London,  1887;  by  Steel),  Lancet,  London,  1888,  ii. 


330  MEDICAL    DIAGNOSIS. 

Sifphilitic  Disease  of  the  Lungs. — Sypliilis  may  lead  to  tubercu- 
lar disease  of  the  lungs.  But  it  will  also  occasion  a  specilic  form 
of  bronchitis,  preceding  the  syphilitic  eruption ;  or  produce  gum- 
mata,  which  may  soften  and  be  eliminated,  and  which,  according 
to  Ricord,  form  in  the  lungs  toward  their  [)eriphery  and  base. 
When  syphilis  manifests  itself  in  the  pulmonary  structures,  it  gives 
rise  to  most  of  the  phenomena  of  phthisis.  The  chief  diiferences 
are,  that  the  nodules  affect  generally  only  one  lung,  most  fre- 
quently the  right,  and  principally  the  base  or  the  lower  part  of 
the  upper  lobe ;  that  they  remain  circumscribed,  not  spreading  to 
the  surrounding  textures;  and  that  they  occasion,  as  a  rule,  neither 
haemoptysis,  nor  fever,  nor  night-sweats,  nor  decided  emaciation^ 
nor  marked  cough  or  rales,  but  dyspnoea  out  of  proportion  to  the 
local  disease.  The  most  common  ])hysical  signs  are  dulncss  on 
percussion,  deficient  fremitus,  altered  vesicular  breath-sounds,  and 
obvious  sinking  in  of  the  supra-  and  infra-clavicular  regions ;  in 
some  instances  signs  of  destruction  of  the  lung  are  found.  Still, 
the  syphilitic  affection  can  be  distinguished  with  certainty  only  by 
the  history  of  the  case,  and  by  the  thickening  of  the  periosteum  of 
the  head  of  one  or  both  clavicles.  Milroy,*  in  his  investigations 
on  soldiers,  also  lays  stress  on  the  thickening  of  the  perichondrium 
of  one  or  more  of  the  upper  cartilages,  with  frequently  a  tumefac- 
tion of  the  soft  parts  between  them  and  the  skin.  To  these  tests 
may  be  added  that  recognized  by  Broderick,f  substernal  tender- 
ness, as  a  means  of  diagnosis  of  acquired  syphilitic  taint.  In  all 
cases,  we  must  be  careful  that  the  thickening  at  the  upper  jiart  of 
the  chest-walls  and  the  altered  resonance  thus  occasioned  be  not 
looked  upon  as  signs  of  a  tubercular  consolidation.  And  as  regards 
the  tenderness,  pain  on  pressure,  as  has  been  correctly  asserted,  is 
met  with  at  the  lower  part  of  the  sternum  in  a  large  number  of 
phthisical  cases. 

Syphilis  of  the  lung  may  also  be  associated  with  syphilitic 
lesions  in  other  organs,  especially  in  the  larynx,  and  we  may  find 
considerable  cough,  with  emaciation,  diarrhoea,  and  albuminuria. 
But  even  then  there  are  no  night-sweats  and  fever  attending  the 


*  British  Anny  Medical  Report,  quoted  in  Annals  of  Military  and  Naval 
Surgery,  vol.  i.,  1863. 

t  Madras  Medical  .Journal,  July,  1865. 


DISEASES   OF   THE   LUNGS.  331 

emaciation,  the  great  debility,  and  the  marked  dyspna3a.  The 
diagnosis  of  syphihs  has  been  made  by  microscopical  examination 
of  the  sputum,  finding  nucleated  granular  cells,  shrivelled  nuclei, 
spindle-cells,  and  remnants  of  a  finely-striated  stroma.* 

The  preceding  diseases  are  most  likely  to  be  confounded  with 
the  stages  of  consumption  prior  to  softening  and  the  formation  of 
cavities.  Next  let  us  review  those  affections  which,  like  phthisis, 
occasion  the  signs  of  excavation,  and  which,  therefore,  may  be 
mistaken  for  its  third  stage  :  they  are,  chiefly,  bronchial  dilatation, 
abscess,  and  gangrene  of  the  lung. 

Bronchial  Dilatation. — A  dilatation  of  the  bronchial  tubes  takes 
place  in  two  forms  :  either  the  tubes  are  uniformly  dilated  and  like 
the  fingers  of  a  glove,  or  else  they  form  cavities  by  undergoing  a 
saccular  enlargement.  The  former  variety  furnishes  the  symp- 
toms and  physical  signs  of  a  case  of  chronic  bronchitis  attended 
with  copious  expectoration.  The  percussion  clearness  may  be 
slightly  lessened,  owing  to  the  condensation  of  the  surrounding 
pulmonary  tissue  ;  the  respiration  may  be  more  strictly  bronchial ; 
but  otherwise  both  symptoms  and  signs  are  those  of  chronic  bron- 
chial inflammation.  In  the  globular  form  of  dilatation  we  meet 
with  all  the  sounds  of  tubercular  excavations :  the  hollow,  blow- 
ing respiration ;  the  hollow,  well-transmitted  voice ;  gurgling ; 
even  metallic  tinkling.  Yet  all  these  phenomena  are  in  strange 
contrast  with  the  almost  unimpaired  health,  and  with  the  non- 
occurrence of  hemorrhage,  of  night-sweats,  and  of  emaciation. 

Hence,  when  we  find  the  signs  of  a  cavity,  and  when  the  general 
symptoms  do  not  indicate  profound  constitutional  disturbance,  we 
may  suspect  a  bronchial  dilatation.  This  suspicion  becomes  a  cer- 
tainty, if  the  cavity  be  at  the  middle  or  the  lower  portion  of  the 
lung,  and  if  the  resonance  on  percussion  be  but  little  impaired. 
For  in  bronchial  dilatation  the  dulness  over  the  seat  of  the  dis- 
ease is  very  slight ;  certainly  not  nearly  so  great  as  that  yielded 
by  the  dense  walls  of  a  tubercular  excavation.  It  is  also  true 
that  the  dulness  on  percussion  is  not  increased  by  respiratory  per- 
cussion, and,  for  the  most  part,  follows,  and  does  not  precede,  the 
auscultatory  signs  of  a  cavity.     We  find  further  evidence  in  the 


*  Sokolowsky,  Deutsche  Medicinische  Woelienschrift,  Sept.  12,  1883  ;  Cube, 
also  Guntz,  quoted  in  Schmidt's  Jahrb.,  No.  6,  1882. 


332  MEDICAL    DIAG^'OSIS. 

stationary  cliaracter  of  the  plivsioal  signs :  for  months  they  do 
not  change ;  whereas  in  phthisis  they  continually  alter  with  the 
advancing  malady.  The  expectoration  of  bronchial  dilatation, 
too,  is  more  abundant  than  that  of  consumption,  and  in  very 
chronic  cases  fetid,  suggesting,  indeed,  at  times,  the  existence 
of  gangrene.  Nor  does  it  look  like  the  s]nitum  of  phthisis,  for 
the  bulk  of  it  is  much  more  Huid,  and  in  the  watery  secretion 
fk)at  small  masses  of  pus  and  detritus  far  less  compact  than  the 
nummular  sputum  of  phthisis.  As  regards  the  cough  of  dilated 
bronchi,  it  is  much  more  persistent,  being  constant  by  day  and  by 
night,  and  only  at  times  relieved  by  expectoration,  which  then 
varies  in  copiousness  according  to  the  size  of  the  sac* 

Skodaf  describes,  as  a  peculiar  physical  sign  present  in  saccu- 
lated bronchial  dilatation,  a  large  and  coarse  crackling,  called  by 
him  the  large  bubbling,  dry  crepitant  rale.  In  a  case  which  came 
under  my  observation,  the  diagnosis  was  made  by  this  ausculta- 
tory sign.  The  patient,  a  boy  aged  twelve  years,  had  swallowed 
a  bone,  which  lodged  in  a  bronchial  tube  and  gave  rise  to  bron- 
chitis and  bronchial  widening.  He  died  subsequently  of  acute 
menino-itis,  and  the  bone  was  found  firmly  embedded  on  one  side 
of  the  elobularly-dilated  bronchial  tube. 

Pulmonary  Abscesses. — Abscesses  of  the  lung  may  form  in  the 
course  of  acute  pneumonia,  but  are  not  then  likely  to  be  mistaken 
for  chronic  phthisis.  Ditferent  is  it  with  abscesses  which  are  de- 
veloped three  or  four  months  after  an  attack  of  pneumonia,  and 
where  the  lung-texture  has  remained  partially  consolidated.  I 
have  seen  not  a  few  examples  of  chronic  induration  of  tlie  lung 
terminating  in  this  way.  A  man  who  was  shot  through  the  lung- 
was  seized,  soon  after  the  injury,  with  inflammation  of  that  organ. 
Percussion  dulncss  and  blowing  respiration  continued  at  the  lower 
part  of  the  left  lung.  One  day,  after  exertion,  he  suddenly  ex- 
pectorated a  considerable  amount  of  pus.  The  signs  of  a  cavity 
were  detected  at  once ;  but  they  subsequently  disappeared,  and 
perfect  recovery  took  place.  In  another  case  of  pneumonia,  the 
disease  in  like  manner  lapsed  into  a  chronic  state.  Five  months 
after  the  acute  attack,  the  evidences  of  an  excavation  became  mani- 


*  Skoda,  Allgem.  Wien.  Med.  Zeitung,  1864,  No.  26. 
■(■  Percussion  and  Auscultutiun. 


DISEASES   OP   THE   LUNGS.  333 

fest  at  the  edge  of  the  right  scapula,  and  existed  there  for  two 
months ;  then,  so  far  as  physical  signs  could  prove,  the  cavity 
closed.  Instead  of  the  hollow,  blowing  respiration  and  gurgling, 
only  a  somewhat  roughened  vesicular  murmur  w^as  perceived. 

Such  is,  however,  not  always  the  termination.  The  abscess 
may  grow  larger  and  larger,  until  the  entire  lung  is  destroyed ; 
amphoric  percussion  note,  amphoric  respiration,  amphoric  voice, 
and,  at  times,  metallic  rales,  being  the  physical  signs  observed. 

These  abscesses  differ  from  bronchial  dilatation  in  not  beina; 
permanent  and  fixed.  They  have  this  in  common  Avith  tubercular 
excavations — they  change.  They  increase  like  these ;  but,  further, 
they  do  what  tubercular  cavities  do  not — they  decrease.  Their 
physical  signs  are  in  every  respect  like  those  of  all  cavities,  and 
vary  with  the  size  of  the  excavation.  Sometimes  metallic  respira- 
tion and  voice  may  be  heard  over  it ;  or  perforation  of  the  pleura 
produces  the  signs  of  pneumothorax  with  effusion.  In  fortunate 
instances  the  pus  is  expectorated,  or  the  abscess  opens  externally, 
and  a  cure  is  thus  established.  But  very  large  abscesses  are  apt 
to  wear  out  the  patient.  Hectic  fever,  and  occasional  hemorrhage, 
attend  them  ;  yet  neither  is  as  constant  a  symptom  as  it  is  in  con- 
sumption. The  sputa  are  usually  copious,  purulent,  and  very  fetid, 
differing  in  this  respect  from  the  ex23ectoration  of  phthisis.  Again, 
abscess  of  the  lung  may  be  distinguished  from  tubercular  disease 
by  being  ordinarily  situated  at  the  base  of  the  organ ;  by  its  fol- 
lowing— although  there  are  excejjtions  to  this  rule,  chiefly  in  septic 
conditions — pneumonic  consolidation  ;  by  the  occurrence  of  copious 
expectoration  being  often,  not  constantly,  sudden ;  but  especially 
by  its  limitation  to  one  lung.  The  other  lung  remains  perfectly 
healthy.  It  may  enlarge,  and  its  murmur  be  more  distinct ;  but 
the  sounds  denote  its  texture  to  be  normal. 

The  small  amount  of  constitutional  disturbance  which  pul- 
monary abscesses  sometimes  entail  is  remarkable.  In  several 
patients,  in  whom  I  have  noticed  abscess  of  the  lung  consequent 
upon  chronic  pulmonary  consolidation,  the  physical  signs  of  a 
large  cavity  were  in  strange  contrast  with  the  regular  pulse,  the 
almost  undisturbed  breathing,  the  slight  cough,  and  the  healthy 
complexion. 

Let  us  tabulate  the  differences  between  a  tubercular  excavation 
and  a  pulmonary  abscess  : 


334  MEDICAL    DIAGNOSIS. 

Pulmonary  Abscess.  Cavity  fkom  Phthisis. 

Signs  of  cavity  usually  at  the  lower  Signs  in  the  upper  lobe. 

lobe. 

Copious  and  puruluiit  sputa,  free  from  Sputa  less  copious,  and  at  lii-st  nuni- 

bacilli.  nuilar,  containing  bacilli. 

Comparatively  small  amount  of  con-  Graver    symptoms,     and     a     dill'erent 

stitutional  disturbance.  history. 

One  lung  affected.  Usually  both  lungs  affected. 

AVliat  has  been  called  '' dissecting  pneumonia,"  a  suppurative 
inflammation  starting  mostly  in  the  peri-lobular  and  peri-bronchial 
tissues  and  dissecting  the  lobules,  and  subsequently  destroying  the 
parenchyma,  leaving  nothing  but  the  bronchial  ramifications  and 
vessels,  has  symptoms  that  are  in  the  main  those  of  abscess,  of 
which,  indeed,  it  forms  a  variety.  The  absence  of  fetid  breath 
and  of  fetid  sputum  distinguishes  it  from  gangrene.* 

Pulmonary  Gangrene. — Another  disease  which  yields  the  signs 
of  an  excavation,  and  which,  like  phthisis,  is  attended  with  wasting 
of  the  body,  here  claims  attention.  Gangrene  of  the  lung  occurs 
either  as  diffused  or  as  circumscribed  gangrene,  after  pneumonia, 
after  wounds  of  the  lung,  from  blows  on  the  chest,  from  poisoned 
blood,  or  from  emboli  in  the  pulmonary  tissue.  The  physical 
signs  are  those  of  a  cavity,  seated  usually  in  the  lower  portion  of 
the  lung.  The  symptoms  are  :  great  and  increasing  prostration, 
dyspnoea,  a  very  pale  face,  a  quick  pulse,  hemorrhage,  emaciation, 
and  a  cough,  followed  by  profuse  purulent  sputa  of  a  greenish 
or  broAvn  color.  But  nearly  all  these  symptoms  happen  also  in 
phthisis.  What  is  characteristic  of  gangrene  is  the  extreme  fetor 
of  the  expectoration  and  of  the  breath.  The  sickening  odor  is  not 
perceived  during  each  act  of  breathing,  but  mainly  after  coughing, 
and,  as  it  were,  in  jets.  It  is  the  symptom  by  which,  especially 
if  taken  in  connection  with  the  signs  of  breaking  up  of  the  pul- 
monary tissue  and  the  sputum,  gangrene  is  with  certainty  recog- 
nized. Some  authors  lay  stress  on  the  fact  that  a  cavity  is  found 
in  onlv  one  lung,  and  at  its  lower  part.  This  is  unquestionably  of 
aid  in  discriminating  l)etween  phthisis  and  gangrene ;  but  it  does 
not  distinguish  between  a  gangrenous  excavation  and  a  simple 

*  See   an   elaborate  paper  by  Hutinel   and  Proust,  Arch.   Gen.  de  Med., 
Nov.  1882. 


DISEASES   OF   THE   LUNGS.  •      335 

abscess  of  the  lung.  The  only  positive  proof  of  gangrene  of 
the  lung  is,  as  just  stated,  that  the  signs  of  breaking  down  of  the 
pulmonary  tissue  are  accompanied  by  a  disgusting  and  more  or 
less  persistent  fetor  of  the  expectoration  and  of  the  breath ;  some- 
times a  sickening,  faintly  sweetish  smell,  sometimes  fsecal,  oftener 
that  of  putrescence.  I  say  persistent,  because  local  gangrene,  on  a 
small  scale,  occurring  around  tubercular  cavities  or  in  bronchitis, 
may  give  rise  to  temporary  extreme  fetor  of  the  breath.  But  it  is 
only  temporary,  and  therefore  not  liable  to  lead  to  fallacious  in- 
ferences. The  ex|)ectoration  may  be  fetid  in  cases  of  bronchial 
dilatation  or  of  abscess  of  the  lung,  but  is  never  brownish,  as  is 
not  uncommon  in  gangrene ;  and  neither  it  nor  the  breath  has 
that  peculiar  gangrenous  odor  which  makes  the  patient  as  unbear- 
able to  himself  as  to  his  attendants.  In  rare  instances  pleurisy 
with  fetid  eifusion  may  occasion  a  fsecal  smell  of  the  expectoration 
and  breath,  which  is  gradually  lost.* 

Yet  in  making;  the  statement  about  hroncliial  dilatation  we  must 
not  overlook  the  fact  that,  as  Dittrich  and  Traube  f  have  shown,  it 
bears  a  marked  relation  to  gangrene.  Decomposition  takes  place 
in  the  secretions  retained  in  the  bronchial  dilatation,  and  ulceration 
of  the  coats  may  ensue,  leading  to  a  gangrenous  process  in  the  sur- 
rounding tissue.  Now,  as  just  mentioned,  the  sputum  even  in 
bronchial  dilatation  may  become  very  fetid.  As,  moreover,  it,  like 
gangrenous  sputum,  may  present  a  dirty  greenish-yellow  color,  and 
separate  on  standing  into  three  distinct  strata,  of  which  the  upper- 
most is  frothy  though  dense,  the  second  serous,  and  the  third  dense, 
containing  pure  pus  and  detritus;  as,  further,  we  meet  in  both  affec- 
tions with  little  solid  masses  of  particularly  offensive  odor  full  of 
fat  and  fine  needle-shaped  crystals  of  margaric  acid, — ^^ve  may  have 
to  depend,  for  a  differential  diagnosis,  on  finding  with  the  micro- 
scope masses  of  degenerated  lung-texture.  Bacteria  and  vibriones 
bespeak  a  similar  pulmonary  origin,  and  they  and  the  substance 
in  which  they  are  embedded  yield  a  purple  or  blue  reaction  with 
iodine.| 

The  complaints  just  considered  exhibit,  thus,  points  in  which 

*  As  in  the  case  reported  by  William  Moore  (Dubl.  Quart.  Jouru.,  May. 
1865). 

t  Gesammelte  Abhandlungen. 

X  Leyden,  Klinisclie  Vortrage,  No.  26,  1871. 


336  MEDICAL    DIAGNOSIS. 

they  are  similar,  and  points  in  which  they  are  dissimilar,  to  pul- 
monary consumption.  Other  affections  might  be  added  which 
are  sometimes  mistaken  for  this  malady,  such  as  ansemia,  dyspep- 
sia, chronic  diarrhoea,  chronic  laryngitis,  chronic  pharyngitis,  and 
thoracic  pains.  But  each  of  these,  althougli  it  may  accompany 
tubercular  consumption  and  even  mask  some  of  its  s}-mptoms, 
lacks,  when  it  is  present  as  an  idiopathic  affection,  those  local 
evidences  of  deposition  and  softening,  lacks  tliat  profound  con- 
stitutional disturbance,  which  form  as  much  a  part  of  j)hthisis  as 
the  disease  in  the  lungs.  The  higher  temperature  the  thoracic 
malady  shows  on  the  chest-walls  is  a  sign  of  some  value  even  in 
early  and  doubtful  cases.- 

In  the  remarks  on  the  diagnosis  of  pulmonary  consum^ition,  the 
complaint  has  been  assumed  to  be  progressive ;  in  rare  instances 
it  7'etrogrades.  Now,  before  dismissing  the  subject  of  phthisis, 
the  signs  by  which  such  retrogression  can  be  discovered  may  be 
alluded  to.  They  are  not  very  fixed.  In  those  cases  in  Mdiich 
many  tubercles  undergo  a  cretaceous  transformation,  calcareous 
particles  are  coughed  up ;  the  signs  of  softening  cease ;  the  apex 
flattens ;  and  a  feeble  murmur,  with  prolonged  expiration  or  a 
harsh  respiration,  with  slight  dulness  on  percussion,  is  all  that 
remains  to  indicate  that  tubercular  disease  has  existed.  It  is 
hardly  necessary  to  say  that  the  cough  stops,  and  that  flesh  and 
strength  return.  These  phenomena  may  be  noted  even  when 
large  cavities  have  existed.  But,  unfortunately,  it  is  not  often 
that  we  have  opportunities  to  make  such  observations. 

We  meet  occasionally  with  instances  in  which  the  physical  signs 
of  an  infiltration  into  the  lung-tissue  depart  with  tolerable  rapid- 
ity. They  occur  in  those  who  have  a  decidedly  scrofulous  aspect, 
enlargement  of  the  glands  of  the  neck,  or  a  scrofulous  inflamma- 
tion of  the  eyes.  In  accordance  with  the  generally  acknowledged 
identity  of  scrofula  and  tubercle,  we  should  be  forced  to  admit 
that  the  disease  in  the  lungs  is  tubercular.  Yet  the  connection 
with  the  enlarged  lymphatics;  the  circumstance  that  the  diminu- 
tion in  size  of  the  glands  is  often  followed  by  increased  pulmonary 
deposits ;  that  these  depositions  are  very  beneficially  influenced 
by  treatment ;  that  they  disappear  sometimes  altogether,  or  only 
reappear  months  afterward, — all  make  it  a  question  whether  there 
be  not  a  scrofulous  disease  of  the  lung  independent  of  a  tubercular, 


DISEASES   OF   THE   LUNGS.  337 

and  one,  moreover,  which  presents  a  much  more  favorable  prog- 
nosis. Among  scrofulous  children  cases  like  those  alluded  to  are 
not  uncommon.  The  disorder  certainly  differs  from  the  ordinaiy 
forms  of  pulmonary  tuberculosis,  and  it  is  not  bronchial  phthisis. 
It  does  not  present  the  paroxysmal  cough,  the  signs  of  pressure 
on  the  trachea  or  the  large  bronchi,  and  the  dull  sound  on  per- 
cussion between  the  scapulte,  which  are  the  common  accompani- 
ments of  enlarged  and  tabercularized  bronchial  glands. 

Some  years  since,  I  had  an  opportunity  of  inspecting  the  lungs 
in  one  of  these  instances  of  supposed  pulmonary  scrofula.  I  was 
treating  a  little  girl  for  this  affection,  when  she  received  a  severe 
injury  which  resulted  in  her  death.  She  had,  when  first  seen,  an 
eruption  on  the  scalp,  sore  eyes,  and  enlarged  cervical  glands.  She 
was  also  much  troubled  by  a  cough  ;  and  marked  dulness  on  per- 
cussion was  discerned  at  the  upper  portion  of  the  left  lung.  Here, 
as  in  fact  throughout  the  whole  of  the  left  lung  and  the  upper 
part  of  the  right,  the  respiration  was  harsh.  But  for  two  weeks 
before  her  death  the  symptoms  and  signs  had  strikingly  improved 
under  cod-liver  oil  and  iodide  of  iron.  She  was  rapidly  losing 
her  cough  and  gaining  strength.  The  dulness  on  percussion  was 
diminishing,  the  respiration  becoming  less  and  less  rough.  At  the 
autopsy  the  greater  part  of  the  left  lung  and  a  portion  of  the  right 
were  found  to  contain  yellowish,  cheesy  deposits,  which  exhibited 
under  the  microscope  a  large  quantity  of  granules  and  some 
shrivelled  cells,  without  distinct  nuclei. 

It  would  be  out  of  place  to  pursue  here  this  intricate  subject. 
I  shall  only  add  that  there  are  no  phenomena  which  serve  as 
a  foundation  for  an  absolute  diagnosis  of  a  scrofulous  in  dis- 
tinction from  a  tuberculous  infiltration.  But  the  rapid  fluctua- 
tion in  the  physical  signs,  their  occurrence  in  those  who  present 
a  strongly  scrofulous  aspect,  and  the  course  of  the  disease,  may 
furnish  a  clue  by  which  to  separate,  as  far  as  they  can  be  sepa- 
rated, cases  of  these  kindred  disorders.  Perhaps  the  absence 
of  haemoptysis  from  among  the  symptoms  may  turn  out  to  be  a 
matter  of  much  importance  in  a  diagnostic  point  of  view.  Cer- 
tainly hemorrhage  did  not  happen  in  any  of  the  cases  of  pulmo- 
nary scrofula  which  have  come  under  my  observation,  ils  regards 
bacilli  in  the  sputum,  I  do  not  know  of  any  observations  on  their 
presence. 

22 


338  MEDICAL   DIAGNOSIS. 

The  Acute  Affections  of  the  Lungs  accompanied  by  Dulness  on 
Percussion. 

In  continuing  the  consideration  of  the  diseases  in  which  duhiess 
on  percussion  is  a  marked  sign,  let  us  glance  at  a  group  of  acute 
affections,  in  the  distinction  of  which  dulness  and  the  physical 
sounds  which  correspond  to  it  hold  an  important  i)art. 

The  acute  diseases  of  the  lungs  are  bronchitis,  pneumonia, 
pleurisy,  and  acute  phthisis.  They  have  some  signs  and  many 
symptoms  in  common.  They  all  present  fever;  they  are  all 
associated  with  more  or  less  dyspnoea  and  thoracic  pain  ;  they 
all  occasion  a  cough.  If,  therefore,  a  physician  meet  with  an 
acute  disease  of  the  chest,  and  find  the  heart  healthy,  lie  at  once 
asks  himself,  Is  the  malady  acute  bronchitis  ?  is  it  acute  phthisis? 
is  it  acute  pneumonia  ?  is  it  acute  j3leurisy  ? 

Now,  the  symptoms  and  signs  of  acute  bronchitis  have  already 
been  discussed.  It  has  been  pointed  out  that  the  want  of  in- 
tensity of  the  fever,  and  particularly  the  unimpaired  resonance 
on  percussion,  separate  bronchial  inflammation  from  all  affections 
which  occasion  consolidation  or  compression  of  the  lung-tissue. 
We  mav  then  proceed  to  examine  the  other  acute  pulmonary 
affections. 

Acute  Phthisis. — When  phthisis  runs  its  course  rapidly,  it 
is  known  as  acute  phthisis,  acute  tuberculosis,  or  galloping  con- 
sumption. This  formidable  complaint  is  met  with  at  the  close 
of  other  diseases,  especially  of  fevers;  but  exposure,  toil,  and 
anxiety  are  also  among  its  exciting  causes. 

Acute  phthisis  shows,  more  even  than  chronic  pulmonary  con- 
sumption, that  the  disease  is  not  simply  one  of  tlie  lungs.  The 
lesions  found  by  the  knife  of  the  pathological  anatomist  arc  indeed 
for  the  most  part  insufficient  to  account  for  the  early  exhaustion 
and  the  emaciation.  The  disorder  often  begins  \vith  a  severe  chill : 
fever  follows;  at  first  like  any  fever  with  anorexia,  quickened 
pulse,  and  elevated  temperature,  but  soon  accompanied  by  ex- 
hausting night-sweats  and  I'apid  emaciation,  which,  in  connection 
with  the  intense  restlessness  and  prostration,  the  high  temperature, 
and  the  supervention  of  delirium,  may  cause  the  febrile  dis- 
turbance closely  to  resemble  typhoid  fever.  The  symptoms  that 
point  to  the  thoracic  malady  are  the  accelerated   breathing,  the 


DISEASES   OF   THE    LUNGS.  339 

cough,  the  copious  expectoration,  the  pain  in  the  chest,  and  the 
spitting  up  of  florid  blood. 

The  physical  signs  are  not  always  the  same.  If  the  tubercles 
be  scattered  through  the  lungs,  no  signs  are  perceived  but  those  of 
diffused  acute  broncldlis;  indeed,  the  sputum  is  the  same  in  compo- 
sition, and  tubercle-bacilli  are  not  found.*  More  commonly  the 
signs  are  like  those  of  chronic  pulmonary  phthisis,  and  associated 
with  the  fever  and  prostration  we  find  the  percussion  didness  of  a 
deposit  or  the  evidences  of  the  destruction  of  the  pulmonary  tissue, 
furnished  by  coarse,  moist  rales,  and  cavernous  breathing. 

When  the  malady  assumes  the  form  resembling  chronic  pul- 
monary consumption,  the  diagnosis  from  bronchitis  is  not  per- 
plexing ;  but  when  its  phenomena  are  similar  to  those  of  acute 
bronchitis,  the  recognition  of  the  tubercular  affection  is  often 
impossible.  This  remark  applies  particularly  to  the  distinction 
of  the  miliary  form,  acute  miliary  tuberculosis,  from  capillary  bron- 
chitis ;  since  the  slight  constitutional  symptoms  and  the  coarseness 
of  the  rales  of  ordinary  bronchial  inflammation  are  too  unlike  the 
phenomena  of  acute  consumption  to  occasion  commonly  much 
difficulty  in  their  discrimination.  But  from  bronchitis  of  the  finer 
tubes  the  diagnosis  can  only  be  effected  by  taking  into  account 
that  repeated  chills,  rapid  emaciation,  and  profuse  sweats  are 
wanting  in  the  bronchial  affection ;  that  the  temperature  is  not 
so  high,  nor  so  irregular ;  that  the  skin  is  more  livid  ;  that  the 
rales  are  more  abundant  and  more  perceptible  at  the  lower  part 
of  the  chest;  and  that,  perhaps,  the  breathing  is  usually  not  so 
hurried.  Moreover,  with  the  great  dyspnoea,  there  are  generally 
frequent  and  violent  fits  of  coughing,  and  marked  chest  pains,  in 
the  acute  tubercular  maladv.  Yet  none  of  these  sig^ns  are  con- 
vincing  proofs.  The  presence  of  dulness  on  percussion,  or  the 
sinking  in  at  the  upper  part  of  the  chest,  the  occurrence  of  hem- 
orrhage, and  the  longer  duration  of  the  case  are  alone  conclusive 
evidence  in  favor  of  acute  tubercular  disease.  Hemorrhage  is, 
however,  by  no  means  so  constant  in  the  acute  as  in  the  chronic 
form  of  the  affection. 

Much  the  same  symptoms  will  enable  us  to  distinguish  between 
acute  tuberculosis  of  the  miliary  form  and   broncho-pneumonia, 

*  Jaksch,  Klinische  Diagnostik,  1887. 


340  MEDICAL    DIAGNOSIS. 

except  that  we  can  draw  no  inference  from  the  dulness  on  per- 
cussion,- fiirtlier  than  that  its  early  occurrence,  with  the  bronchial 
symptoms,  points  to  the  pneumonic  malady,  its  later  occurrence, 
atler  the  grave  symptoms,  to  the  tubercular. 

When  the  dulness  on  percussion  is  well  defined,  acute  plithisis 
might  be  mistaken  for  ordinary  pneumonia.  But  the  signs  of 
deposit  and  of  softening  in  both  lungs,  and  the  seat  of  the  lesions 
at  the  apices,  show  diftcrences  from  a  disease  which  in  the  large 
majority  of  instances  is  one-sided  and  at  the  lower  part  of  the  lung, 
which  exhibits  a  characteristic  sputum,  and  in  which  breaking  up 
of  the  pulmonary  tissue  is  so  rare. 

Yet  there  are  cases  of  acute  phthisis  that  display  sym})t()ms  and 
signs  very  puzzling,  and  strongly  simulating  those  of  pneumonia. 

A  person  in  perfectly  good  health  is  seized,  after  exposure,  with 
cough  and  fever.  They  are  aceomjjanied  by  dyspnoea,  and  soon 
we  find  signs  of  consolidation  of  the  lower  lobe,  or  of  the  entire 
lung.  The  dulness  on  percussion  does  not  disappear  under  treat- 
ment ;  and  a  hollow,  blowing  respiration  and  gurgling,  usually 
first  perceptible  at  the  angle  of  the  scapula,  gradually  ap[)ear, 
and  indicate  the  formation  of  a  cavity.  Emaciation,  which  began 
from  the  onset,  progresses  more  rapidly,  and  goes  hand  in  hand 
with  extreme  prostration  and  profuse  perspirations.  The  sputa 
are  copious  and  purulent,  but  at  no  time  mixed  with  blood.  The 
other  lung  is  carefully  examined ;  all  its  sounds  are  normal.  The 
case  remains  in  this  condition  for  several  weeks,  the  patient  tem- 
porarily improving  under  stimulants,  yet,  on  the  whole,  growing 
weaker  and  tormented  with  fever  of  very  irregular  type.  A  slight 
roughening  of  the  inspiratory  murmur,  or  dry  rales  at  the  apex  of 
the  unaffected  lung,  attract  attention,  and  dulness  on  percussion 
and  the  signs  of  deposition  become  there  more  and  more  manifest. 
A  post-mortem  examination  exhibits  nearly  the  whole  of  one  lung 
converted  into  a  uniform  yellowish  or  grayish  mass  of  tubercle, 
and  containing  one  or  several  large  excavations ;  not  a  vestige  of 
healthy  lung-structure  is  to  be  seen.  Scattered  tubercles  are  found 
in  the  other  lung,  and  mainly  at  its  apex. 

The  case  just  described  is  one  of  a  group  which  every  physician 
has  met  with.  The  beginning  of  the  case  as  one  of  pneumonia 
or  catarrhal  pneumonia,  the  persistent  consolidation,  the  occur- 
rence of  rales  and  of  subsequent  dulness  on  percussion  at  the 


DISEASES    OF    THE    LUNGS,  341 

upper  part  of  the  previously  unaffected  side,  the  continuance  of 
the  disease,  and  the  prostration  and  sweats  which  accompany  it, 
permit  us  to  foretell  its  nature  and  the  probable  fatal  termination. 

I  may,  in  this  connection,  again  revert  to  the  views  of  those 
who,  like  Niemeyer,  accord  to  inflammation  and  the  deo;encration 
of  its  products  the  chief  place  in  the  production  of  consumption. 
Sucih  cases  as  just  described  would  be  classed  as  acute  pneumonie 
phthisis,  the  result  of  caseous  infiltration  of  the  pulmonary  tissues 
and  the  disintegration  of  the  cheesy  infiltration.  It  is  difficult 
with  our  present  knowledge  of  the  bacillar  origin  of  consum23tion 
to  explain  them.  It  is  supposed  that  the  bacilli  that  are  formed 
have  readily  fastened  on  the  altered  lung.  Those  who  look  upon 
pneumonic  phthisis  as  essentially  inflammatory  maintain  that  in 
true  acute  tuberculosis  an  eruption  of  miliary  tubercles  in  the  lungs 
and  in  other  organs  takes  place,  and  that  repeated  chills,  high 
temperature,  intense  dyspnoea,  and  physical  signs  more  those  of 
an  extensive  bronchitis,  characterize  it. 

Acute  phthisis  may  simulate  other  affections  besides  those  of 
the  chest.  It  has  at  times  the  delirium  and  prostration,  the  dry 
tongue,  and  the  bronchial  rales  of  typhoid  fever.  The  diarrhoea 
and  the  abdominal  symptoms  are,  however,  wanting.  Yet  simul- 
taneous deposition  of  tubercles  in  the  intestine  may  cause  these ; 
and  in  this  case  the  only  mark  of  difference  from  typhoid  fever 
is  the  absence  of  an  eruption  ;  unless,  even  under  these  circum- 
stances, we  are  aided  by  the  fact  pointed  out  by  Fox,  that,  unlike 
the  persistent  high  temperature  of  typhoid  fever  with  its  regular 
diminution  when  the  disease  declines,  the  thermometric  record  in 
acute  phthisis  shows  great  and  sudden  variations,  bearing  no  rela- 
tion to  the  number  of  respirations  or  to  the  beats  of  the  pulse. 
The  temperature  may  vary  many  times  in  the  course  of  the  dis- 
ease to  the  extent  of  six  or  seven  degrees.  Acute  phthisis  lacks 
the  wild  eye,  the  gastric  disturbance,  the  rigid  muscles,  the  con- 
vulsions, of  meningitis;  or  the  active  delirium  it  occasionally 
produces  might  be  attributed  to  inflammation  of  the  membranes 
of  the  brain. 

Acute  phthisis  sometimes  progresses  with  extreme  rapidity.  I 
have  seen  a  case  terminate  in  thirteen  days.  It  is  almost  invari- 
ably fatal.  Yet  it  has  its  periods  of  deceptive  improvement :  the 
disease  may  proceed  speedily  toward  softening,  and  then  remain 


342  MEDICAL   DIAGNOSIS. 

for  a  time  stationary.  In  some  instances  the  termination  in  death 
is  the  result  of  eomi)lieations,  as  of  tubereuUir  meningitis,  or  of 
erysipelas  of  the  tliroat  and  tlie  bronchial  tubes.* 

Acute  Pneumonia. — Inllammation  of  the  lung,  or  "cronp- 
ous  pneumonia,"  is  the  type  of  the  acute  pulmonary  affections. 
The  hot,  dry  skin,  the  flushed  face,  the  quickened  pulse,  the  ex- 
tremely rapid  breathing,  the  thoracic  pain,  the  cough,  and  the 
peculiar  expectoration,  point  out  at  once  the  acute  nature  of  the 
attack  and  the  organ  which  is  disturbed.  Beginning  commonly 
with  a  chill,  or  with  flushes  of  heat,  the  disease  progresses  with 
the  symptoms  indicated.  A  few  of  these  require  a  detailed 
description. 

The  expectoration  is  characteristic.  It  consists  at  first  of  a 
glairy  mucus ;  soon  it  becomes  more  viscid,  and  acquires  the  ap- 
pearance dependent  upon  the  admixture  of  blood  with  the  mucus 
and  exudation -matter,  to  ^vhich  the  term  rusty-colored  has  been 
given.  This  rusty  sputum  is  pathognomonic  of  pneumonia ;  yet 
cases  run  their  course  without  it.  The  expectoration  is  sometimes 
like  prune-juice,  or  it  is  purulent.  Both  augur  badly  :  both  in- 
dicate that  destruction  of  the  lung-tissue  has  begun. 

The  shortness,  or  increased  frequency,  of  breathing  is  another 
marked  symptom.  The  patient  draws  from  forty  to  eighty  breaths 
a  minute ;  but  the  pulse,  although  rapid,  does  not  quicken  in 
proportion.  Pneumonia,  therefore,  forms  an  exception  to  the 
rule  that  with  greater  frequency  of  breathing  the  pulse  rises. 
This  perverted  pulse  respiration-ratio  may  be  made  an  impor- 
tant element  in  the  diagnosis.  The  febrile  symptoms  are  ordi- 
narily severe  ;  still,  they  are  not  associated  with  decided  cerebral 
disturbance.  Headache  is  common ;  delirium  is  rare,  and,  ^vhen 
it  occurs,  is  indicative  of  great  danger.  The  heat  of  the  skin  is 
burning ;  and  the  flush  on  the  cheek  is  so  decided  that  by  this 
and  the  hurried  breathing  alone  the  disease  may  often  be  recog- 
nized. The  flush  on  the  cheek  is  not  accidental.  It  is  sometimes 
very  dark,  and,  according  to  Bouillaud,  is  most  obvious  when  the 
inflammation  affects  the  apex  of  the  lung. 

The  urine  is  high-colored,  and  that  of  fever.  A  notable  cir- 
cumstance about  it  is  that  nitrate  of  silver  does  not  precipitate 

*  Lasegue,  Arch.  Gen.  de  Med.,  May,  1873. 


DISEASES    OF   THE    LUNGS.  343 

its  chlorides.  They  commonly  disappear  during  consolidation  of 
the  lung,  and  their  reappearance  shadows  forth  returning  health. 
The  vanishing  of  the  chlorides  from  the  urine  happens  also  in 
other  acute  affections ;  but  in  pneumonia  it  is  most  constant  and 
most  absolute. 

The  physical  signs  which  denote  that  the  lung-tissue  has  be- 
come the  seat  of  acute  inflammation  vary  with  the  effects  of  the 
inflammation.  In  the  first  stage,  or  that  of  engorgement,  and 
beo-inniup-  exudation  in  the  air-cells,  into  which,  however,  the  air 
is  still  capable  of  entering,  there  is  only  a  slight  impairment  of 
the  normal  resonance  on  percussion.  The  vesicular  murmur  is  at 
first  somewhat  altered  ;  it  may  be  feebler  or  harsher.  But  soon 
are  heard  with  each  act  of  inspiration,  and  limited  to  the  inspira- 
tion, numerous  rapidly-evolved,  very  fine,  crackling  sounds,  the 
"  crepitant"  or  vesicular  rales. 

As  the  exudation  becomes  firmer,  and  the  tissue  of  the  lung 
solidifies  by  occlusion  of  the  air-cells,  the  stage  of  red  hepatization 
is  before  us.  Now  all  the  signs  of  complete  consolidation  are  dis- 
cerned. We  find  decided  dulness  on  percussion,  unchanged  by 
full  inspiration;  blowing  respiration  in  its  purity,  high-pitched 
and  tubular-sounding;  bronchophony;  and  increased  vocal  fre- 
mitus. Rales  from  the  accompanying  bronchitis  are  heard  with 
extreme  distinctness  through  the  solidified  tissue  (Skoda's  con- 
sonating  rales) ;  so  are  the  sounds  of  the  heart.  A  crepitant  rale 
is  still  here  and  there  perceptible,  or  the  ear  catches  a  friction- 
sound, — a  sign  that  inflammation  has  involved  the  pleura. 

When  the  exudation  is  reabsorbed  or  expectorated,  the  signs  of 
consolidation  become  less  and  less  perfect.  A  vesiculo-bronchial 
succeeds  to  the  bronchial  breathing.  The  dulness  on  percussion 
lessens  ;  crepitant  rales — not,  however,  so  fine  as  at  the  onset  of  the 
affection,  and  mixed  with  larger  moist  rales — return  ;  the  cough  in- 
creases ;  the  expectoration  becomes  more  copious,  loses  its  tenacity 
and  rusty  color,  and  is  found  to  contain  broken-down  exudation- 
corpuscles,  and  a  large  quantity  of  fat ;  the  dyspnoea  diminishes, 
— all  phenomena  indicative  of  the  breaking  up  of  the  exudation, 
and  of  the  return  of  air  into  the  vesicles.  If,  instead,  the  exuda- 
tion be  converted  extensively  into  pus,  and  the  lungs  soften,  the 
physical  signs  are  the  same  as  in  the  second  stage.  The  rarity  of 
excavations  of  sufficient  size  explains  why  gurgling  and  the  signs 


344 


MEDICAL   DIAGNOSIS. 


of  a  cavity  are  not  perceived.  We  suspect  the  mischief  that  is 
going  on  within  the  chest  from  tlie  protracted  dyspnoea,  the  in- 
creasing mpidity  of  pulse,  the  purulent  or  brownish  sputa,  the 
pinched  features,  the  dry  tongue,  and  the  mental  wandering. 
Recovery  may  take  place  even  then.     This  third  stage  is  indeed 

Fig.  27. 


Percussrun  duliiess 
Bronchial  breathin 
BroucUial  voice 
Increased  fremitus 


Diagram  illustrative  of  perfect  pulmonary  consolidation,  such  as  happens  in  the 
second  stage  of  pueuniouia. 

not  so  much  an  abrupt,  suddenly-established  process,  as  it  is  tlie 
extension  and  greater  diffusion  of  a  state  that  may  be  found  in 
portions  of  the  lung  which  to  the  eye  have  all  the  appearance  of 
red  hepatization.  In  every  instance  of  red  hepatization  the  micro- 
scope shows  that  in  parts  the  lung-tissue  is  infiltrated  with  granules 
and  is  undergoing  softening,  and  it  is  probable  tliat  this  breaking 
down  occurs,  even  though  on  a  small  scale,  in  all  cases  of  pneu- 
monia which  recover.  It  is  often  impossible  to  determine  that 
the  third  stage  has  arrived ;  and  death  may  take  place  long  before 
the  lung  presents  the  condition  which  pathologists  term  gray 
hepatization.  With  reference  to  the  diagnosis  of  this  third  stage, 
we  may  suspect,  from  the  symptoms,  that  the  pulmonary  tissue  is 
seriously  damaged.  But  we  can  never  know  it,  unless  we  find 
the  physical  signs  of  extensive  softening;  and  in  the  large  majority 
of  cases  this  cannot  be  done. 


DISEASES   OF   THE   LUNGS. 


345 


The  morbid  phenomena,  physical  signs  and  symptoms  of  the 
malady  correspond,  then,  usually  in  this  manner  : 

Pneumonia. 

I.  Stage  of  engorgement     Crepitant     rale ;     slight     Cough  ;  beginning  dysp- 
and    beginning    ex-        percussion  duluess.  noea    and    rapidly-de- 

udation.  vcloped  fever  heat. 


II.  Stage  of  solidifica-  Percussion  dulness ; 
tion  of  lung-tissue  bronchial  respiration; 
(red  hepatization).  bronchophony. 


III.  Stage    of   softening     The  same  physical  signs 
(gray  hepatization).  as  in  the  second  stage  ; 

unless  large   abscesses 
have  formed. 


Rusty-colored  sputum ; 
dyspnoea ;  cough  ;  high 
fever,  temperature  gen- 
erally above  103°,  with 
marked  evening  ex- 
acerbations and  morn- 
ing remissions.  ' 

Chills  ;  prostration,  etc.  ; 
purulent  or  brown- 
ish sputum;  generally 
high  temperature,  104° 
to  105°,  or  upwards. 


Here  is  a  disease  Avhich  presents  such  striking  symptoms  and 
signs  in  nearly  all  its  phases,  in  which  the  sputa  are  so  peculiar, 
the  hurried  breathing  so  evident,  the  physical  signs  so  distinct, 
that  error  is,  with  ordinary  care,  difficult.  It  becomes  still  more 
so,  if  a  few  of  the  pathological  peculiarities  of  pneumonia  be  borne 
in  mind  :  the  fact  that  it  is  rarely  double ;  that  it  comparatively 
seldom  affects  the  upper  lobe  of  the  lung,  and  that  it  is  often  ac- 
companied by  the  signs  of  slight  pleurisy  or  of  bronchitis.  The 
temperature  of  pneumonia  generally  ranges  between  103°  and 
105°.  It  is  not  unusual  for  it  to  drop  suddenly  on  the  ninth  or 
eleventh  day,  and  the  disease  to  terminate,  as  it  were,  by  crisis. 
In  some  instances  sudden  disturbance  of  the  circulation  takes 
place  with  the  rapid  development  of  cyanosis.  These  symptoms 
bespeak  a  heart-clot. 

But  let  us  contrast  pneumonia  with  the  various  diseases  with 
which  it  may  be  confounded.  In  its  first  stage,  on  account  of 
similar  signs,  the  acute  inflammatory  disorder  is  sometimes  mis- 
taken for  oedema  of  the  lung,  or  for  the  pulmonary  engorgement 
which  takes  place  in  some  fevers ;  and  still  more  frequently  these 
morbid  states  are  mistaken  for  it. 


346  ilEDICAL    DIAGNOSIS. 

Pulmonary  (Edema. — This  consists  in  the  transudation  of  serum 
into  the-  air- vesicles.  It  may  be  acute,  the  result  of  sudden  con- 
gestion, such  as  that  following  injuries  of  the  brain  or  irritation 
of  the  par  vagum ;  or  it  may  arise  at  the  termination  of  acute 
affections  of  the  lungs.  It  is  more  usually,  however,  chronic, 
and  is  seen  as  a  dropsy  of  the  air-cells,  associated  with  dropsies 
elsewhere,  and  in  connection  with  organic  disease  of  the  liver, 
heart,  or  kidneys.  The  characteristic  manifestations  of  oedema — 
be  it  acute  or  chronic — are  embarrassed  breathing,  expectoration 
of  frothy  serum,  and  crepitating  and  tine  bubbling  sounds  dif- 
fused over  both  lungs,  and  dependent  upon  the  fluid  in  the  air- 
cells  and  small  bronchial  tubes.  It  presents,  thus,  many  points 
of  similarity  to  the  first  stage  of  acute  pneumonia.  The  dysp- 
noea, the  crepitation  in  the  lung,  may  well  mislead  ;  but  we  can- 
not err,  if  the  frothy  sputum,  the  general  distribution  of  the 
rales,  their  somewhat  coarser  charactei',  the  bluish  lip,  the  noisy 
breathing,  and  the  absence  of  fever  be  taken  into  account.  In 
acute  oedema  these  phenomena  are  but  the  precursors  of  death. 
In  chronic  oedema  the  rales  are  persistent,  and  so  is  the  difficulty 
of  respiration.  The  patient  has  usually  to  be  propped  up  with 
pillows,  otherwise  he  cannot  breathe. 

Pulmonary  Engorgement  in  Fevers. — In  fever  of  low  type  a 
crepitant  rale,  which  might  be  supposed  to  be  a  proof  of  beginning 
inflammation  of  the  lung,  is  often  heard  at  the  back  part  of  the 
chest.  The  sound  is  the  consequence  of  pulmonary  congestion. 
It  is  perceived  over  both  lungs ;  and  this,  taken  in  connection 
with  the  history  of  the  case,  and  Avith  the  rale  not  being  followed 
by  decided  shortness  of  breath  and  by  dulness  on  j)crcussion  and 
blowing  respiration,  shows  that  it  is  not  dependent  on  inflamma- 
tion of  the  pulmonary  tissue.  It  is  necessary  to  be  aware  that 
these  fine  rales  may  occur  in  fevers  without  being  due  to  a  true 
pneumonia ;  as  otherwise  the  patient  is  apt  to  be  treated  for  a 
disease  of  the  lung  which  has  no  existence. 

Hypostatic  Congestion. — Besides  the  lung  congestion  just  referred 
to  as  occurring  in  fevers,  we  have  other  causes  producing  a  marked 
congestion,  or  hypostatic  pneumonia.  We  find  it  in  enfeebled 
hearts,  in  those  whose  blood  is  impoverished  and  who  are  for  any 
length  of  time  bedridden,  and  in  instances  of  acute  rheumatism. 
In  the  dependent  portions  of  the  lungs  the  signs  of  congestion 


DISEASES   OF   THE   LUNGS.  347 

show  themselves  first ;  and  they  are,  besides  the  signs  of  accelerated 
and  impeded  circulation  and  deficient  aeration  of  blood,  slight 
expectoration,  scarcely  any  fever,  varying  shortness  of  breath, 
somewhat  impaired  resonance  on  percussion  at  the  lower  part  of 
the  chest, — generally  more  over  the  right  than  over  the  left  lung, 
— feebleness  of  respiratory  murmur,  and  a  few  fine  and  coarse 
moist  rales. 

In  its  second  stage,  owing  to  the  cough  and  dyspnoea,  and  in 
part,  also,  to  some  similarity  in  the  physical  signs,  acute  pneu- 
monia may  be  confounded  with  pulmonary  apoplexy,  acute  pleu- 
risy, acute  phthisis,  and  acute  bronchitis. 

Pulmonary  Apoplexy. — An  effusion  of  blood  into  the  texture 
of  the  lung  is  generally,  although  by  no  means  invariably,  accom- 
panied by  external  hemorrhage  and  by  great  difficulty  of  breathing. 
Over  the  effused  blood  there  is  dulness  on  percussion,  and  the  ear 
hears  an  enfeebled  or  bronchial  respiration.  Around  the  seat  of 
the  mishap  it  encounters  moist  rales.  Now,  here  are  signs  bear- 
ing some  resemblance  to  those  of  pneumonia.  But  we  miss  from 
among  them  the  decided  fever.  We  find,  on  the  other  hand,  not 
blood  intimately  mixed  with  the  expectoration,  but  pure  blood, 
florid  or  sooty-looking,  almost  devoid  of  air,  in  not  large  amount, 
at  times  surrounded  with  muco-purulent  matter,  and  ordinarily 
voided  for  a  number  of  days.  On  close  scrutiny  a  grave  disease 
of  the  heart  is  generally  detected  to  explain  why  an  extravasation 
of  blood  into  the  pulmonary  structure  has  taken  place.  Then 
we  most  frequently  find  the  branch  of  the  pulmonary  artery  lead- 
ing to  the  infarcted  part  plugged  by  an  embolus,  which  has  been 
formed  in  the  right  cavities  of  the  heart  or  been  washed  in  through 
the  general  venous  system,  and  most  commonly  affects  the  right 
lung.  Again,  we  have  more  pain  than  in  pneumonia,  and  the 
dyspnoea  is  different.  In  pneumonia  it  augments  up  to  the  height 
of  the  malady.  In  pulmonary  apoplexy  it  is  greatest,  and  it  is 
very  great,  when  the  blood  is  extra vasated ;  after  that  it  declines. 
Yet  the  two  affections  often  coexist.  The  closure  of  the  vessel 
produces  a  pneumonia  from  embolism,  or  the  blood  acts  as  a  for- 
eign body,  and  around  it  is  lighted  up  an  inflammation  of  the 
lung-structure,  which  is  apt  to  have  its  seat  in  the  posterior  part 
of  the  lower  lobe  of  the  right  lung ;  further,  the  inflammation 
may  be  the  starting-point  of  caseous'  degeneration  and  phthisis. 


348  MEDICAL   DIAGNOSIS. 

Pneumonia  from  embolism  may  be  also  caused  bv  a  pva^mic  con- 
dition, and  the  clots  may  have  their  origin  in  bedsores,  in  ulcers, 
and  in  various  forms  of  suppuration.  The  plugs  are  saturated 
with  ichor,  and  metastatic  abscesses  result.  The  symptoms  are 
the  same,  and  we  can  only  make  a  diagnosis  by  the  history  ;  there 
are  the  same  circumscribed  spots  of  consolidation,  and  the  same 
kind  of  pain,  which  is  also  often  found  to  be  associated  with  a 
localized  pleurisy,  sometimes  followed  by  effusion. 

Pulmonary  apoplexy  is  met  with  in  connection  ^vith  other 
than  thoracic  affections.  Observations  by  Brown-Sequard  and  by 
Ollivier  have  proved  its  association  with  central  nervous  lesions, 
and  have  demonstrated  its  occurrence  on  the  same  side  as  the 
brain  lesion  ;  *  which  is  not  the  case  with  reference  to  the  ordinary 
acute  pidmonary  diseases,  for  these  Rosenbach  f  has  shown  to  be 
much  more  frequent  on  the  paralyzed  side  of  the  body,  and  there- 
fore, generally,  on  the  side  opposite  to  the  cerebral  mischief. 

Of  the  other  diseases  mentioned  which  resemble  pneumonia,  the 
distinguishing  points  need  not  be  here  fully  described.  Acute 
pleurisy  will  be  farther  on  more  particularly  studied.  With  regard 
to  acute  phthisis,  it  is  only  necessary  to  repeat  that  cases  are  en- 
countered, apparently  of  pneumonia,  in  which,  after  the  symp- 
toms of  acute  inflammation  of  the  lung  pass  off,  those  of  phthisis 
come  into  the  foreground.  With  reference  to  acute  bronchitis,  I 
shall  merely  recall  that  the  dyspnoea  is  not  so  great,  and  that  no 
percussion  dulness  is  yielded  by  an  inflamed  bronchial  membrane. 

Percussion  is  thus  of  signal  value  in  the  diagnosis  of  pneumo- 
nia. In  fact,  when  bronchitis  complicates  pneumonia,  and  loud, 
dry  rales  take  the  place  of  the  blowing  respiration,  it  is  our  only 
trustworthy  guide.  A  single  tap  on  the  chest  which  elicits  an 
absolutely  dull  sound  tells  the  difference  between  pure  bronchitis 
and  the  inflammation  of  the  bronchial  mucous  membrane  which 
accompanies  inflammation  of  the  parenchymatous  structure  of 
the  lung. 

The  form  of  pneumonia  most  liable  to  be  mistaken  for  bron- 
chitis is  the  pneumonia  of  childhood  or  of  old  age,  broncho- 
pneumonia or  catarrhal  pneumonia.  This  affection  has  already 
been  described  in  examining  into  capillary  bronchitis.     But,  as 

*  Arch.  Gen.  de  Med.,  Aug.'  1873.  f  Centralblatt,  No.  16,  1879. 


DISEASES    OF    THE    LUNGS.  349 

the  disease  may  also  occur  in  adults,  and  has  special  features,  a 
few  words  more  will  not  be  out  of  place. 

Catarrhal  Pneumonia. — It  supervenes  upon  catarrhal  bronchi- 
tis, except  in  instances  in  which  it  arises  from  inhaling  irritating 
gases.  The  bronchial  attack  is  usually  severe,  but  it  may  be  so 
slight  as  to  be  readily  overlooked.  The  spread  of  the  disease 
to  the  lung-texture  is  attended  with  rapid  rise  of  temperature. 
When  the  disorder  attacks  adults,  it  is  apt  to  seize  upon  those 
debilitated  by  previous  disease ;  it  much  more  commonly  affects 
the  upper  lobes  than  does  ordinary  sthenic  pneumonia,  and  is 
generally  bilateral.  As  the  broncho-pneumonia  merely  solidifies 
lobules,  the  signs  of  marked  consolidation  are  wanting,  or  are 
perceptible  over  only  a  small  space.  Crepitation  is  not  common, 
but  small  moist  rales  are  ;  bronchial  breathing  and  increased 
fremitus  show  only  over  limited  points ;  and  the  sputum  is  not 
rusty  and  viscid,  but  catarrhal.  Cough  and  expectoration,  some- 
times absent  in  croupous  pneumonia,  are  always  present  in 
broncho-pneumonia. 

Catarrhal  pneumonia  pursues  a  much  slower  course  than  croup- 
ous pneumonia,  and  generally  yields  only  gradually.  The  con- 
solidation may  continue  stationary  for  weeks,  showing  a  fever 
with  marked  daily  remissions  and  exacerbations,  and  then  slowly 
disappear.  But,  on  the  other  hand,  caseous  degeneration  and 
breaking  down  of  the  lung-texture  may  follow,  or  extended  tuber- 
cular infiltration  may  take  place.  Phthisis,  in  truth,  is  in  adults 
a  not  uncommon  termination  ;  in  children,  too,  this  may  happen, 
or  rachitis  develop  itself,  or  an  ill-defined  but  persistent  cachexia, 
and  a  great  tendency  to  catch  cold. 

Pneumonia  is  thought  by  many  to  be  but  the  local  expression 
of  a  general  disease,  a  lung  fever,  and  thus  its  occasional  epidemic 
occurrence  is  explained.  It  would  be  out  of  place  here  to  discuss 
this  view.  A  peculiar  bacillus  has  been  described  by  Friedlander 
as  present,  and  as  accounting  for  its  supposed  infectious  character. 
But  it  is  still  doubtful  whether  this  pneumococcus  is  characteristic. 
Nor  is  it  certain  whether  by  it  we  can  distinguish  the  sporadic 
instances  of  the  disease  from  those  which  belong  to  an  infectious 
malady.  In  truth,  with  our  present  knowledge,  there  are  no  signs 
or  symptoms  which  clearly  separate  the  local  from  the  general 
affection. 


350 


MEDICAL   DIAGNOSIS. 


There  are  further  two  other  forms  of  inflammation  of  the  lung 
which  have  not  been  elsewhere  considered,  and  which,  as  they 
present  somewhat  peculiar  symptoms,  require  to  be  explained. 
They  are  typhoid  pneumonia  and  bilious  pneumonia. 


Fig.  28. 


Pneumococciis  (diplococcus)  of  Friedliinder,  without  the  capsule,  from  a  pure  culture 
upon  fji'latiii  from  the  sputum  in  a  case  of  croupous  pneumonia  at  the  Pennsylvania 
liospital.     Drawn  by  Dr.  Joseph  Leidy,  Jr. 


Typhoid  Pneumonia. — Inflammation  of  the  lung  may  be  from 
its  onset  attended  with  extreme  prostration.  This  form  of  the 
disease  has  been  made  a  matter  of  warm  controversy,  both  as  to 
the  symptoms  which  characterize  it  and  as  to  the  relation  it  bears 
to  other  varieties  of  the  malady.  Now,  any  one  who  reads  the 
dissimilar  descriptions  given  of  it  will  become  convinced  that 
under  the  term  typhoid  pneumonia  the  most  various  disorders 
have  been  ranged  together.  On  the  one  hand,  it  has  been  applied 
exclusively  to  the  inflammation  of  the  lung  which  may  complicate 
typhus  or  typhoid  fever ;  on  the  other  hand,  it  has  been  made  to 
include  an  idiopathic  fever  in  which  the  aff'ection  of  the  respira- 
tory organs  is  occasionally  wanting.  To  neither  of  these  diseases 
ought  to  belong  the  name  typhoid  pneumonia,  since  in  both  the 
inflammation  of  the  lung  is  but  an  incidental  accompaniment. 


DISEASES    OF    THE    LUNGS.  351 

Typhoid  pneumonia  is  pneumonia  with  symptoms  of  a  typlioid 
type,  and  marked  by  rapid  failure  of  tlie  vital  powers.  The  in- 
flammation of  the  lung  arising  in  the  course  of  typhus  or  typhoid 
fever  will  of  course  be  apt  to  present  this  character ;  but  the 
malady  is  also  noticed  as  a  consequence  of  phlebitis ;  as  super- 
vening in  cases  of  erysipelas,  of  Bright's  disease,  and  of  delirium 
tremens  ;  or  as  the  sole  apparent  affection.  It  happens  not  unfre- 
quently  in  epidemics,  and  is  very  often  observed  among  negroes. 
Its  ravages  on  the  plantations  of  South  Carolina  and  Georgia  are 
sometimes  frightful.  It  is,  also,  very  fatal  among  troops  in  the 
field,  placed  under  unfavorable  hygienic  conditions. 

The  physical  signs  are  those  of  the  sthenic  form  of  the  disease, 
except,  perhaps,  that  the  crepitant  rale  is  less  frequent.  Most  of 
the  same  symptoms,  too,  show  themselves :  cough,  short  breathing, 
and  pain  in  the  chest.  All  of  these  may  be  very  marked,  or  so 
trifling  as  hardly  to  direct  attention  to  the  lungs.  There  is,  how- 
ever, one  symptom  characteristic  and  constant,  and  but  one,  and 
that  is  the  great  tendency  to  sinking.  As  regards  the  expectora- 
tion, it  may  be  rusty-colored ;  yet  occasionally,  even  in  the  early 
stages  of  the  complaint,  it  consists  of  pure  blood.  The  pulse  is 
always  quick,  but  weak.  Dark  sordes  often  collect  on  the  teeth 
and  gums,  as  they  do  in  typhoid  fever.  Pain  is  absent  in  some 
cases,  and  extremely  acute  and  of  a  radiating  character  in  others. 
Concerning  delirium,  we  know  that  it  is  much  more  common  than 
it  is  in  the  sthenic  variety  of  pulmonary  inflammation,  except  this 
affect  the  apex  in  children.  Some  authors  mention  an  eruption. 
It  is,  however,  questionable  whether  the  cases  which  came  under 
their  notice  were  not  tyj)hus  or  typhoid  fever,  in  the  course  of 
which  pneumonia  appeared.  The  flush  on  the  face  in  the  low  type 
of  the  malady  under  consideration  is  usually  of  a  dusky  hue,  but 
not  invariably  :  a  pink-colored  blush,  extending  sometimes  all 
over  the  body,  seems  to  have  specially  attracted  the  attention 
of  observers.  The  disease  is  always  dangerous,  and,  as  Stokes* 
points  out,  resolution  is  extremely  slow.  Chronic  hepatization, 
with  or  without  a  low  hectic  fever,  or  a  lurking  congestion,  may 
continue  for  weeks. 

The  symptoms  of  typhoid  pneumonia  are  at  times  strangely 

*  Diseases  of  the  Chest. 


352  MEDICAL   DIAGNOSIS. 

mixed  up  with  those  produced  by  otlicr  conditions.  In  many 
districts  in  which  the  comphiint  is  prevalent,  it  bears  the  distinct 
impress  of  malaria.  Ao-ain,  articular  symptoms  seem  to  predomi- 
nate in  some  reg-ions  of  country,  and  in  some  epidemics.  Gibbes* 
speaks  of  an  acute  pain  in  the  l)ack  })art  of  the  eye,  in  the  ears,  or 
in  the  side  of  the  neck,  attended  with  stiffness  of  tiie  muscles; 
and  of  a  swcllino;  of  the  tonsils,  and  of  the  submaxillary  and  sub- 
lingual glands,  which  he  states  to  be  of  evil  augury.  Dickson, f 
drawing  his  description  of  the  disease  from  cases  observed  in  and 
around  Charleston,  poi"trays  several  forms,  the  most  common  of 
which  exhibits  a  respiration  hurried  and  irregular ;  heavy  sigh- 
ing ;  a  feeling  of  weight  at  the  prsecordial  region,  with  nausea 
and  vomiting ;  and  a  tongue  clean,  but  red.  Delirium  is  present 
from  the  beginning,  and  does  not  subside  until  recovery  takes 
place.  The  duration  of  such  attacks  averages  from  six  to  ten 
davs.  In  another  form,  there  are  at  the  onset  ffreat  gastric 
oppression  and  vomiting,  and  signs  of  vascular  excitement.  But 
muscular  prostration  and  debility  soon  happen  ;  and  lividity  of 
the  countenance,  petechial  spots,  and  coma  are  symptoms  which 
usher  in  dissolution. 

Bilious  Pneumonia. — Jaundice  and  other  indications  of  hepatic 
and  gastric  derangement  are  not  usual  in  ordinary  sthenic  pneu- 
monia. They  may  be  occasionally  caused  by  the  inflammation 
spreading  to  the  liver,  or  may  be  noticed  w^iere  no  evidence  of 
such  an  occurrence  exists  in  consequence  of  the  state  of  the  blood. 
But  in  the  pneumonia  so  general  in  the  spring  and  the  autumn 
in  the  miasmatic  regions  of  some  of  the  Southern  and  Western 
States  of  this  conntry,  hepatic  symptoms  are  common,  and  mark 
a  special  type  of  the  disease,  known  as  malarial  pneumonia,  bilious 
pneumonia,  or  by  the  familiar  name  of  "bilious  pleurisy." 

This  form  of  inflammation  of  the  lung  is  simply  ])neumonia, 
sthenic  or  asthenic,  on  whose  features  the  stamp  of  malaria  is  im- 
printed. The  chill  witli  which  it  begins  is  usually  protracted,  and 
is  followed  by  pain  in  the  side,  by  fever,  by  hurried  breathing,  by 
cough,  and  by  tenacious,  rusty-colored  expectoration.  The  pain 
in  the  side,  which  depends  upon  accompanying  pleurisy,  is  sharp 
and  severe,  and  renders  the  respiration  irregular.     The  sputum  is 

*  Amer.  Journ.  Med.  Sci.,  1842.  f  Elements  of  Medicine. 


DISEASES   OF   THE   LUNGS.  .35.'j 

at  times  rusty-colored,  while  at  others  a  frothy  and  bloody  serum 
or  pure  blood  is  expectorated.  The  fever  shows  the  type  of  the 
disease.  It  is  much  more  paroxysmal  than  in  the  other  varieties 
of  the  malady.  This  peculiarity,  and  the  obvious  symptoms  of 
hepatic  and  gastric  disorder,  are  indeed  the  only  absolutely  dis- 
tinguishing traits  of  bilious  pneumonia.  The  febrile  exacterba- 
tions  are  stated  by  Manson,  of  North  Carolina,  to  be  preceded, 
during  the  morning  hours,  by  an  insensible  chill, — a  coolness  of 
the  ends  of  the  nose,  fingers,  and  toes,  which,  in  grave  cases,  ex- 
tends over  the  entire  extremities.*  The  same  writer  dwells  on  the 
irritability  of  the  intestinal  canal,  and  the  occurrence  of  greenish- 
black,  viscid  and  inodorous  stools.  This,  and  the  diminution  of 
the  dyspnoea,  diaphoresis,  and  a  copious  secretion  of  urine,  point 
to  a  favorable  issue  of  the  disease.  On  the  other  hand,  it  may 
terminate  fatally  with  symptoms  indicative  of  great  prostration. 

The  physical  signs  are  those  of  ordinary  acute  pneumonia. 
Bronchial  breathing  and  bronchophony  are  said  to  be  more  often 
absent,  or  to  appear  and  disappear  rapidly.  It  is  certain,  if  this 
be  true,  that  in  these  instances  the  malady  could  not  have  been 
inflammation,  but  was  more  probably  a  collapse  of  the  pulmonary 
tissue.  Any  one,  indeed,  who  compares  the  various  statements 
made  with  reference  to  the  disease,  must  have  been  struck  with 
the  fact  that  cases  of  congestive  fever  in  w^hich  the  lungs  have 
become  simply  engorged,  or  perhaps  collapsed,  and  cases  of  in- 
flammation of  the  lung  arising  in  the  course  of  remittent  fevers, 
are  included  in  the  same  description  with  true  cases  of  idiopathic 
bilious  pneumonia. 

The  nature  of  an  inflammation  of  the  lung  bearing  so  decidedly 
the  livery  of  malaria  has  given  rise  to  warm  controversies.  Re- 
garded by  some  as  nothing  more  than  a  special  form  of  remittent 
or  intermittent  fever,  in  which  the  lungs  are  made  to  bear  the 
burden  of  the  disease,  it  is  by  others  held  to  be  simply  a  variety 

*  Virginia  Med.  Journ.,  Sept.  and  Oct.  1857.  See  'also  an  excellent  essay 
on  the  subject  by  W.  F.  Howard,  North  Carolina  Med.  Journ.,  Feb.  1859  ;  Eam- 
say,  Charleston  Med.  Journ.,  vol.  vi.  ;  Merrill,  New  Orleans  Med.  and  Surg. 
Journ.,  July,  1851 ;  Drake  on  the  Diseases  of  the  Interior  Valley  of  North 
America;  Morehead,  "Diseases  of  India;"  D.  K.  Fox,  Transact.  Louisiana 
Med.  Soc,  New  Orleans,  1886,  viii. ;  and  W.  W.  Taylor,  New  York  31  ed. 
Journ.,  1887. 

23 


354 


MEDICAL   DIAGNOSIS. 


of  pneinnonia,  occasioiKcl  l)y  tlio  onliiiarv  causes  of  this  affec- 
tion, but  owing  its  peculiar  symptoms  to  its  happening  in  those 
in  whose  svstenis  the  poison  of  malaria  has  been  slumbering. 

Acute  Pleurisy. — Acute  pleurisy  has  been  so  often  inci- 
dentally mentioned,  that  a  description  of  its  main  points  will 
here  suffice.  The  first  effect  of  the  inflammation  is  to  redden  the 
pleural  membrane ;  an  exudation  of  a  soft,  grayish,  and  easily- 
detached  lymph  then  takes  place.  This  constitutes  the  first  or 
drv  stage  of  the  disease ;  and  if  the  two  inflamed  surfaces  unite, 
the  disorder  does  not  pass  beyond  this  stage.  Often,  however, 
along  with  the  exudation  of  lymph  occurs  an  effusion  of  .serum, 
which  produces  a  special  train  of  phenomena,  and  gives  rise  to 
the  second  stage^  or  that  of  liquid  effusion. 

Fig.  29. 


Friction  sound. 


Roughening  of  the  pleura  from  inflammation  ;  a  small  amount 
of  fluid  has  begun  to  collect. 


The  physical  signs  of  the  dry  stage  are  impaired  movement 
of  the  chest,  a  feebler  respiration,  and  a  friction  sound  of  vary- 
ing extent  and  intensity.  The  first  tw^o  signs  are  caused  by  the 
patient  instinctively  recoiling  from  expanding  the  lung,  because 


DISEASES   OF   TPIE   LUNGS. 


355 


of  the  pain  it  occasions.  The  mechanism  of  the  friction  sound, 
its  nature,  its  superficial  character  and  want  of  uniformity,  have 
been  pointed  out  in  a  previous  part  of  this  chapter.  In  the 
stage  of  effusion  the  physical  signs  differ  according  to  the  amount 
of  fluid  the  pleural  cavity  contains.  A  moderate  quantity  of 
liquid  only  constricts  the  lung-texture,  and  leaves  the  bronchial 
tubes  intact ;   a  large    accumulation    compresses    everything ;    it 


Fig.  30. 


Great  diilness 

Absent  voice 

Absent  respiration. 
Absent  fremitus 


Examination  of  the  posterior  portion  of  the  chest  while  a  large  effusion  is 
occupying  the  left  pleural  cavity. 

drives  all  air  out  of  the  lung,  pushes  it  into  a  small  space  against 
the  vertebral  column,  and  displaces  the  liver  or  heart.  Wherever 
the  fluid  accumulates  there  is  dulness  on  percussion,  When  the 
patient  is  in  the  erect  posture,  the  flat  sound  on  striking  the  chest 
and  the  sense  of  resistance  to  the  finger  are  marked  at  the  lower 
part  of  the  thorax,  since  the  fluid  naturally  settles  there.  The 
line  of  dulness  is,  however,  not  the  same  in  front  as  it  is  behind. 
It  is  generally  much  higher  behind,  and  alters,  of  course,  with  the 


356  MEDICAL   DIAGNOSIS. 

changing  (|u;uitity  of  effn.sioii,  and  somewhat  with  the  position 
of  tlie  patient.*  When  he  lies  npon  his  liice,  the  flnid  gravitates, 
if  not  eircuniscribed  by  adhesions,  toward  the  anterior  chest-walls, 
and  the  percussion  dulness  posteriorly  becomes  far  less  percep- 
tible. 

Where  the  elFusion  is  at  all  extensive,  the  intercostal  spaces  are 
widened  and  their  depressions  effaced.  The  side  ap})ears  to  the 
eye  distended,  fluctuation  may  be  perceived,  and,  owing  to  the 
absolute  com})ression  of  the  lung,  no  sound  is  heard  over  the  chest 
when  the  i)atient  breathes,  or  speaks,  or  coughs.  In  more  mod- 
erate collections  of  fluid,  the  cessation  of  sound  is  n(jt  so  abso- 
lute. There  is  an  ill-defined,  deep-seated  respii-ation,  and  the 
voice  reaches  the  ear  with  tolerable  distinctness,  and  occasionally 
with  a  peculiar  bleating  resonance  attending  it.  But,  as  large 
collections  of  fluid  are  more  common  than  small  ones,  the  former 
set  of  phenomena  are,  at  the  height  of  the  disease,  more  frequent 
than  the  latter. 

Above  the  liquid  there  is  mostly  increased  resonance  on  per- 
cussion, or  a  tympanitic  sound.  Various  explanations  have  been 
given  of  this  phenomenon.  It  has  been  attributed  to  the  complete 
compression  of  the  lung ;  it  has  been  thought  to  be  due  to  its 
slight  condensation.  Whatever  be  the  true  explanation,  the  fact 
of  its  occurrence  is  undeniable.  This  tympanitic  sound  is  more 
manifest  at  the  upper  part  of  the  chest  in  front ;  it  may,  indeed, 
be  found  in  front  when  it  does  not  exist  behind.  In  some  cases 
the  sound  has  an  amphoric,  in  others  a  cracked-metal  character. 
When  the  ear  is  applied  above  the  line  of  percussion  dulness, 
it  recognizes  occasionally  a  friction  sound ;  and  near  the  spinal 
column  posteriorly,  where  the  compressed  lung  lies,  it  perceives 
almost  invariably  distinct  bronchial  respiration  and  bronchophony. 

When  the  fluid  begins  to  be  absorbed,  the  voice  becomes  more 
audible  over  the  scat  of  the  effusion,  the  vocal  vibrations  may  be 
felt  by  the  fingers,  and  the  respiration  is  again  heard.  But  for  a 
lono;  time  it  continues  enfeebled,  and  its  character  is  indetermi- 
nate  ;  it  is  neither  vesicular  nor  purely  bronchial.     As  more  and 

*  Calvin  Ellis  has  described  a  peculiar  curve  of  the  percussion  line,  which, 
from  its  resemblance  to  the  letter  S,  has  been  named  by  Garland  "  the  letter 
S  curve"  of  pleurisy,  and  is  regarded  as  characteristic  (Pneurnono-Dynamics, 
1878,  and  New  York  Medical  Journal,  Nov.  1879). 


DISEASES    OF    THE    LUNGS.  357 

more  of  the  fluid  disappears,  the  voice  becomes  more  and  more  dis- 
tinct ;  a  friction  sound  finally  shows  that  the  roughened  surfaces 
have  come  in  contact ;  and  the  dulness  on  percussion  is  replaced 
by  a  far  clearer  sound.  False  membranes  now  unite  the  two 
pleurae ;  the  intercostal  sj)aces  resume  their  normal  shape ;  and 
the  chest  is  either  restored  to  its  natural  size,  or  is  left  perma- 
nently somewhat  contracted.  The  bronchial  breathing  near  the 
vertebral  column  persists  for  a  long  time,  since  the  compressed 
lung  unfolds  but  slowly. 

These  physical  signs  have  been  discussed  first  because  they  are 
the  most  important  elements  in  the  diagnosis  of  pleurisy.  The 
symptoms,  indeed,  often  hardly  attract  attention ;  and  if  we  trusted 
to  them,  we  should  be  groping  in  the  dark.  Pleurisy  mostly 
begins  with  a  chill,  followed  by  fever  and  by  a  dry,  irritating 
cough.  The  most  distinctive,  though  not  a  constant,  symptom 
of  the  first  stage  is  the  sharp,  acute  pain,  the  "  stitch  in  the  side." 
It  is  commonly  felt  under  the  nipple  or  in  the  axilla,  and  is 
somewhat  increased  on  pressure.  Its  seat  by  no  means  always 
corresponds  to  the  seat  of  the  friction  sound.  As  the  effusion 
takes  place,  the  pain  disappears,  dyspnoea  becomes  evident,  and 
the  patient  ordinarily  lies  on  the  affected  side.  The  febrile  symp- 
toms and  dry  cough  continue ;  yet  neither  is  marked,  and  both 
disappear  long  before  the  fluid  is  entirely  absorbed. 

Pleurisy  may  be  idiopathic,  or  it  may  be  an  attendant  upon 
other  diseases,  such  as  affections  of  the  lungs,  measles,  scarlatina, 
typhoid  and  typhus  fevers.  It  may  also  be  caused  by  wounds 
of  the  thoracic  walls,  by  Bright's  disease,  rheumatism,  gout, 
diphtheria,  pyaemia,  and  other  morbid  states. 

The  malady  with  which  acute  idiopathic  pleurisy  is  most  likely 
to  be  confounded  is  acute  pneumonia.  Both  are  affections  occa- 
sioning dyspnoea;  both  are,  in  the  majority  of  cases,  one-sided; 
both  present,  in  their  most  advanced  stages,  dulness  on  percus- 
sion. But  the  dulness  in  the  latter  disease  is  far  less  absolute 
than  in  the  former ;  nor  do  we,  save  in  very  rare  instances,  meet 
with  a  tympanitic  or  amphoric  percussion  sound  in  pneumonia, 
while  in  pleurisy,  as  we  have  just  seen,  it  is  far  from  unusual 
above  the  level  of  the  fluid.  In  those  few  cases  in  which  an 
amphoric  or  a  tympanitic  sound  is  perceived  in  pneumonia,  the 
peculiar  tone  is  most  obvious  over  the  consolidated  tissue. 


358  MEDICAL   DIAGNOSIS. 

The  other  physieal  signs  of  the  two  diseases  show  still  less 
similitude.  The  absence  of  respiration,  of  vocal  resonance,  and 
of  thrill  is  in  striking-  conti'ast  with  the  loud  blowing  res})iration, 
the  strong  chest-voice,  and  the  increased  vocal  thrill  of  pneu- 
monia. There  are,  however,  exceptional  cases  of  pleuritic  effusion, 
in  which  bronchial  breathing  is  heard  all  over  one  side  of  the 
chest.  Especially  docs  this  happen  if  pneumonic  consolidation 
accompany  the  effusion ;  but  even  in  simple  compression  of  the 
lung,  and  where  the  collection  of  liquid  is  not  extensive,  bronchial 
respiration  may  be  perceived.  The  difficulty  of  distinguishing 
from  pneumonia  such  cases  of  pleurisy,  in  which  probably  the 
lung-tissue  is  compressed  around  the  bronchial  tubes  but  these 
are  not  encroached  upon,  is  great.  As  aids  in  diagnosis,  we  seek 
for  the  dilatation  of  the  chest ;  we  note  the  peculiarities  of  the 
breathing,  which,  although  blo\ving,  is  mostly  fainter  than,  and 
unlike,  the  high-pitched,  brazen  respiration  of  pneumonia ;  we 
find  that  the  percussion  dulness  over  the  upper  jjart  and  where 
the  bronchial  respiration  is  most  distinct  is  not  very  great,  and, 
especially,  that  it  disappears  on  respiratory  percussion ;  we  observe 
that  the  voice  is  less  strong  and  ringing,  and  has,  perhaps,  a  bleat- 
ing tone ;  and  we  take  into  account  the  appearance  of  the  sputum 
and  the  character  of  the  fever.  But,  leaving  these  cases  out  of 
consideration,  the  diagnosis  between  the  two  affections  is  easy. 
It  may  be  thus  summed  up : 

Pleurisy.  Pneumonia. 

Sharp     pain;      friction     sound;     dry  Dull  pain ;  crepitant  rale ;  cough,  fol- 

cough  ;  impaired  chest-motion.  lowed  by  expectoration. 

In   stage   of    effusion,  obliteration    of  In     stage    of    hepatization,  none   of 

the  intercostal  spaces  ;    enlargement  these  signs  are  manifest. 

of  the  side ;  displacement  of  several 

viscera. 

In    the   large    majority  of    cases,  dul-  Dulness,  with    marked  bronchial   res- 

ness,  with   enfeebled   or   absent  res-  piration ;     distinct    thoracic    voice; 

piration,  voice,  and  fremitus.  increased  vocal  fremitus. 

Decubitus    is    often    on    the    affected  Decubitus  not  peculiar ;  sometimes  on 

side.  the  sound  side. 

Sputa  frothy  ;    rarely  any  rales  in  the  Sputa   rusty-colored ;    rales   from    ac- 

chest.  companying     bronchial    inflamma- 
tion common. 

Febrile  symptoms  usually  slight.  Febrile  sj-mptoms  severe. 


DISEASES    OF    THE    LUNOS.  359 

Temperature  record  irregular,  and  not  Temperature  record  much  more  char- 
characteristic  ;  rarely  103°.  acteristic.  Temperature  rises  rap- 
idly soon  after  onset,  then  is  contin- 
uous, with  marked  evening  exacer- 
bations from  two  to  three  degrees, 
and  morning  remissions.  Often 
reaches  105°.  May  show  sudden 
elevations  and  striking  falls  in  the 
whole  course  of  the  fever.  Toward 
end  of  disease  generally  rapid  de- 
fervescence. High  temperature  not 
uncommon,  especially  in  pneumo- 
nia of  upper  lobe. 


In  the  first  stage  of  pleurisy  the  pain  might  cause  the  disease 
to  be  confounded  with  pleurodynia  or  intercostal  neuralgia.  In 
all  three  pain  is  the  prominent  symptom.  Let  us  see  how  it 
differs  in  each  : 

Pleurodynia. — Pleurodynia  is  described  as  a  form  of  muscular 
rheumatism.  But  frequently  it  is  myalgia,  or  pleurisy  which 
does  not  pass  beyond  the  dry  stage.  Of  this  nature  are  most  of 
the  fugitive  chest-pains  from  which  phthisical  patients  suffer. 
Yet  there  are  cases  in  which  no  signs  whatever  of  pleurisy  exist, 
but  which  are  attended  with  as  much  pain  as  pleurisy.  The  pain 
of  pleurodynia  is,  indeed,  often  excessively  severe ;  the  patient 
refrains  from  deep  breathing,  since  every  motion  of  his  chest  in- 
creases his  suffering.  The  pain  is  augmented  by  movements  of 
the  arm  and  by  pressure,  and  is  generally  associated  with  tender- 
ness. Pleurodynia  shares  with  pleurisy  the  feeble  respiration  and 
the  want  of  action  of  the  affected  side.  It  differs  from  it  by  the 
absence  of  friction  sound  and  of  fever ;  by  the  shifting  pain,  often 
double-sided  ;  and  by  the  greater  tenderness  of  the  chest-walls. 

Intercostal  Neuralgia. — In  ansemic  women  and  in  consumptives 
acute  thoracic  pain  is  not  uncommonly  the  result  of  an  intercostal 
neuralgia.  The  same  want  of  expansion  of  the  chest  and  the  same 
enfeebled  breathing  as  in  pleurodynia  are  here  noted,  also  the  same 
absence  of  fever  and  of  pleural  friction.  The  distinguishing  marks 
of  intercostal  neuralgia  are  :  its  intermittent  character ;  its  frequent 
association  with  uterine  disturbance,  especially  with  leucorrhoea, 
and  the  limitation  of  the  tenderness  to  special  points  in  the  course 
of  the  affected  nerve.    Valleix  has  drawn  attention  to  three  pain- 


360  MEDICAL    DIAGNOSIS. 

I'll!  >;pots  whieli  are  tender  to  the  toiu-h  :  one  at  the  exit  of  the 
nerve  ivoin  the  spinal  eolnmn,  the  seeond  in  the  axillary  region, 
and  the  third  near  the  sternum  or  in  the  epigastric  region.  It  is 
on  the  left  side  that  we  are  most  apt  to  find  intercostal  neuralgia, 
and  between  the  sixth  and  ninth  ribs  tinit  the  painful  places  are 
usually  detected. 

Pain  occurs  also  in  diseases  affecting  the  lung-texture.  There  is 
pain  of  a  dull  nature  in  pneumonia,  of  a  more  severe  character  in 
cancer.  But  the  pain  is  so  dissimilar,  and  the  coexisting  symptoms 
are  so  unlike,  that  the  error  of  confounding  these  maladies  with 
pleurisy,  on  account  of  the  pain,  is  not  likely  to  be  committed. 

Diseases  presenting  Dilatation  of  the  Chest,  Displacement  of 
the  Liver  or  Heart,  and  Dyspnoea. 

A  group  of  diseases  may  here  be  studied,  all  of  which  occasion 
more  or  less  dilatation  and  prominence  of  the  chest,  and  all  of 
Avhich  are  attended  with  decided  shortness  of  breath.  In  bron- 
chitis and  pneumonia  a  slight  increase  in  the  diameters  of  the 
chest  may  take  place ;  but  it  is  not  a  sign  of  any  diagnostic  im- 
portance. In  the  recognition  of  emphysema,  pneumothorax,  and 
pleuritic  effusions,  the  dilatation  of  the  thorax  forms  one  of 
the  main  elements  ;  moreover,  it  is  often  combined  with  marked 
dyspnoea  and  with  displacement  of  the  liver  or  heart.  These 
affections,  then,  may  be  examined  in  the  same  connection,  and 
compared  with  one  another,  and  incidentally  with  several  less 
common  diseases  which  present  similar  manifestations. 

The  history  and  signs  of  emphysema  were  given  Avhen  treating 
of  the  diseases  accompanied  by  clearness  on  percussion.  It  was 
then  mentioned  that  in  many  instances  the  prominence  of  the 
chest  is  circumscribed.  Such  cases  cannot  be  mistaken :  the 
bulging  is  too  limited.  But  when  the  emphysema  is  more  gen- 
eral, and  an  entire  side  of  the  chest  or  the  whole  chest  becomes 
dilated,  or  when  the  inflated  lung  displaces  the  liver  or  heart,  the 
affection  comes  into  the  group  under  consideration.  A  patient 
seeks  advice  for  shortness  of  breath.  His  chest  is  inspected,  and 
looks  enlarged.  The  physical  signs  prove  that  the  disease  is  not 
one  of  the  heart.  What,  then,  is  it  ?  Is  it  an  effusion  into  the 
pleura  ?  is  it  pneumothorax  ?  is  it  emphysema  ?     A  tap  on  the 


DISEASES    OF    THE    LUNGS.  361 

chest  ffoes  far  toward  showinu;  whether  it  be  th(!  former.  If  the 
sound  rendered  be  resonant,  it  is  not  liquid  in  the  chest  that  is 
producing  tlie  disturbance :  the  disorder  is  either  pneumotliorax 
or  emphysema. 

Pneumothorax. — Of  all  thoracic  maladies,  pneumothorax  is 
the  one  the  similarity  of  which  to  extensive  dilatation  of  the  air- 
cells  is  the  greatest.  In  both,  the  large  quantity  of  air  occasions 
increased  clearness  on  percussion ;  in  both,  there  is  considerable 
and  persistent  difficulty  of  breathing ;  in  both,  the  distention  of 
the  chest  and  the  displacement  of  organs  may  be  obvious.  In 
pneumothorax,  however,  the  symptoms  and  signs  are  associated 
with  different  conditions.  Pneumothorax  is  an  accumulation  of 
air  in  the  pleural  cavity,  but  it  is  something  more :  the  entrance 
of  air  is  soon  followed  by  the  effusion  of  liquid. 

Air  is  let  into  the  cavity  of  the  chest  by  the  pleura  being 
perforated  by  wounds,  or,  as  is  more  common,  by  its  partial 
destruction  consequent  upon  disease  of  the  lung.  It  is  in  this 
way  that  pneumothorax  originates  in  the  course  of  tubercular 
softening,  of  gangrene,  of  pneumonia,  or  from  the  bursting  of 
a  distended  air- vesicle  or  of  a  dilated  bronchial  tube.*  In  the 
large  majority  of  instances  it  occurs  in  tubercular  patients. 

When  air  passes  from  the  lung  into  the  pleura,  it  usually  hap- 
pens during  a  paroxysm  of  coughing.  The  pain  which  ensues 
is  most  intense ;  and  the  frightful,  suddenly-developed  dyspnoea, 
the  anxious  expression  of  the  face,  soon  show  how  seriously  respi- 
ration is  interfered  with.  If  death  do  not  take  place,  symptoms 
of  pleurisy  with  effusion  manifest  themselves ;  and,  as  in  pleurisy, 
the  patient  lies  ordinarily,  but  not  invariably,  on  the  affected  side. 

The  distinctive  marks  of  pneumothorax  are  furnished  by  its 
physical  signs.  The  ingress  of  air  into  the  pleural  cavity  widens 
the  chest,  effaces  the  depression  of  the  intercostal  spaces,  and 
occasions  an  extremely  clear,  or,  more  correctly  speaking,  a  tym- 
panitic, sound  on  percussion.  The  air  prevents  the  lung  from 
expanding :  hence  there  is  an  enfeebled  or  absent  respiration, 
except  near  the  spinal  column,  where  the  compressed  organ  lies, 
and  where  the  breathing  is  bronchial.  The  hand,  if  laid  on  any 
other  portion  of  the  chest,  feels,  when  the  patient  speaks,  no  thrill, 

*  Case  recorded  by  Taylor,  Prov.  Med.  Journ.,  vol.  i.,  1842. 


362 


MEDICAL  DIAGNOSIS. 


and  no  vocal  vibration  is  detected  by  the  ear.  Wlicn  the  perfo- 
ration has  not  closed,  and  the  air  rnshes  into  the  artificial  cavity 
produced  by  the  separation  of  the  two  surfaces  of  the  ]ileura,  the 
res])iratlon  is  amplioric,  or  it,  the  voice,  and  the  rales  are  all 
accompanied  by  a  distinct  metallic  ring ;  respiratory  percussion, 
too,  changes  the  sound  elicited,  rendering  it  duller.  Drops  of 
fluid  falling  into  the  cavity,  or  the  bursting  of  bubbles  on  the 
surface  of  the  liquid  in  the  })leura,  arc  also  echoed  to  the  ear 
with  a  metallic  sound,  and  are  often  heard  as  a  silvery  tinkle. 

Fig.  31. 


Physical  signs  in  pneumotliorax  on  tho  right  side.  The  heart  is  oliserved  to  be  dis- 
placed toward  tlie  left,  as  actually  liappened  in  the  case  from  which  the  outline  was 
taken.  The  percussion  resonance  on  tlie  riglit  side  was  tymjianitic,  extending  some- 
what over  the  left  margin  of  the  sternum  ;  the  fremitus  was  annulled  ;  the  voice 
metallic. 


The  presence  of  the  fluid  in  the  pleural  cavity  gives  rise  to  a 
dull  sound  on  percussion  at  the  lower  part  of  the  chest,  and  to  a 
splash,  perceptible  to  the  ear  and  to  the  finger,  when  the  thorax  is 
suddenly  shaken.    This  continues  until  the  effusion  increases,  and 


DISEASES    OF    THE    LUNGS.  363 

until  the  opening  in  the  membrane  closes,  the  air  disappears,  and 
the  case  resolves  itself  into  one  of  chronic  pleurisy, — the  most 
favorable  termination  of  pneumothorax. 

Now  let  us  compare  the  physical  signs  with  those  produced  by 
emphysema.  The  sound  on  percussion  in  both  is  very  clear,  or  is 
tympanitic ;  more  so,  however,  in  pneumothorax,  which,  in  addi- 
tion, exhibits  dulness  at  the  lower  part  of  the  chest.  The  respira- 
tion in  both  is  feeble.  But  it  is  feebler  in  pneumothorax,  and  not 
accompanied  by  a  long,  laborious  expiration ;  besides,  it  is  often 
amphoric,  and  attended  with  metallic  voice  and  tinkling, — phe- 
nomena which  dilated  air-cells  cannot  occasion.  Moreover,  there 
can  be  no  splashing  sound  in  emphysema,  and  this  always  exists 
in  pneumothorax,  except  in  those  rare  instances  in  which  there 
is  no  fluid  in  the  pleural  cavity ;  on  the  other  hand,  the  displace- 
ment of  the  heart  is  generally  much  greater  in  pneumothorax, 
and  the  dilatation  of  the  chest  more  apt  to  be  one-sided.  Yet 
too  much  stress  has  been  laid  on  the  latter  point  as  a  means  of 
distinction ;  for  emphysema  may  be  one-sided,  and,  on  the  other 
hand,  pneumothorax,  as  I  know  from  meeting  with  a  number  of 
instances,  may  occur  on  both  sides.  In  some  cases  we  are  aided  in 
the  discrimination  by  noticing  that  bulging  is  percej^tible  over  the 
displaced  heart,  and  that  a  metallic  echo  follows  the  cardiac  sounds. 

The  physical  signs  of  the  two  diseases  are  thus  very  different ; 
so,  too,  are  many  of  the  symptoms.  Difficulty  of  breathing  exists 
in  both.  But  in  emphysema  it  takes  more  the  form  of  attacks 
of  asthma ;  besides,  it  does  not  set  in  suddenly  and  with  intensity, 
and  remain  intense.  In  pneumothorax  the  patient  remembers  to 
have  been  seized  with  a  pain  in  his  chest,  since  which  period  he 
has  been  continuously  very  short  of  breath. 

Yet  there  are  exceptions  to  this :  there  are  cases  in  which  the 
symptoms  occasioned  by  perforation  of  the  pleura  are  from  the 
onset  so  slight  as  not  to  attract  the  least  attention.  Such  cases 
cannot  be  recognized,  save  by  their  physical  signs.  Among  these, 
dilatation  of  the  chest,  with  the  widened  intercostal  spaces,  the 
displacement  of  the  liver  or  heart,  and  the  exaggerated  and  altered 
resonance  on  percussion  are  most  valuable  in  preventing  the  dis- 
ease from  being  confounded  with  some  aifections  which  otherwise 
give  rise  to  many  of  the  same  phenomena.  In  large  cavities,  for 
instance,  the  respiration  and  voice  may  be  metallic ;  metallic  tink- 


364  MEDICAL   DIAGNOSIS. 

ling,  nay,  even  a  succussion  soiuul,  may  occur.  But  the  prominent 
chest,  the  extremely  clear,  tympanitic,  or  metallic  sound  on  percus- 
sion, bordered  by  the  line  of  absolute  dulness  due  to  the  ell'iision, 
are  not  met  with.  The  liistory  also  is  different,  and  the  dyspnoea 
is  not  so  iireat.  The  same  dissimihu'ities  will  prevent  us  from 
mistaking  ibr  pneumothorax  a  pneumonia  in  which  the  percussion 
sound  over  the  consolidated  lung  is  tympanitic.  And  a  study  of 
the  pliysical  signs,  too,  will  at  once  enable  us  to  discern  whether 
the  dithculty  in  breathing,  though  it  be  suddenly  developed,  and 
apparently  imder  circumstances  which  make  the  swallowing  of  a 
foreign  body  seem  likely,  be  due  to  this  cause,  or  to  perforation 
of  the  pleura  and  pneumothorax.^' 

There  is,  however,  a  morbid  condition  which  exhibits  nearly 
all  the  signs  and  many  of  the  symptoms  of  pneumothorax,  and 
which,  were  it  more  frequent,  would  be  the  source  of  constant 
errors  of  diagnosis, — diaphragmatic  hernia. 

Of  this  rare  affection  we  know  but  little.  Yet,  thanks  to  Bow- 
ditch,f  what  we  do  know  of  it  teaches  us  that  a  protrusion  of  the 
abdominal  organs  through  the  diaphragm  will  generally  dilate  one 
side  of  the  chest,  compress  the  lung,  and  displace  the  heart.  It 
will  do  more :  it  results  in  dyspnoea ;  and,  as  the  stomach  or  in- 
testines are,  for  the  most  part,  the  viscera  which  find  their  way 
into  the  chest,  metallic  tinkling  and  a  tympanitic  sound  on  per- 
cussion are  detected.  These  are  also  signs  of  pneumothorax. 
There  is,  indeed,  no  mode  of  separating  the  two  diseases,  except 
by  attention  to  the  history  of  the  case,  by  noting  that  the  dyspncea 
of  the  former  suddenly  appears  and  as  suddenly  disappears,  that 
it  has  often  existed  from  birth,  and  that  the  metallic  tinkling 
hajDpens  when  the  patient  is  not  breathing,  and  is  mixed  up  with 
the  rumblino;  sound  arising;  in  the  stomach  or  intestine. 

It  has  been  made  a  question  whether  we  can  distinguish  ordi- 
nary cases  of  pneumothorax  from  these  very  rare  ones  which  are 
supposed  to  occur  tcithout  perforation.  Now,  even  admitting  that 
such  really  happen  as  a  sequence,  for  instance,  of  decomposition  in 
pleuritic  effusions,  there  are  no  signs  by  which  we  can  recognize 
them  with  certainty.     It  has  been  claimed  for  them  that  there  is 

*  As  in  a  case  of  the  disease  communicated  to  me  bj^  Dr.  "Walter  P.  Atlee. 
I  Buflalo  Med.  Jouru.,  June  and  July,  1853. 


DISEASES   OP   THE   LUNGS.  365 

110  antecedent  history  of  a  chronic  puhnonary  affection,  particu- 
larly of  phthisis,  that  there  is  not  that  suddenly-occurring  severe 
pain  and  extreme  dyspnoea,  that  the  sputum  and  breath  are 
never  offensive,  that  metallic  tinkling  is  absent,  or  rare  and 
inconstant,  and  that  the  amphoric  breathing  is  not  so  well  de- 
veloped or  so  clearly  defined.  If  in  a  case  of  perforation,  how- 
ever, the  opening  have  closed,  the  physical  signs,  it  is  granted, 
are  the  same.* 

Chronic  Pleurisy. — Chronic  pleurisy  is  the  third  of  the 
group  of  more  usual  affections  which  are  characterized  by  dilata- 
tion of  the  chest,  by  displacement  of  the  intra-thoracic  viscera, 
and  by  shortness  of  breath.  It  is  true  that  acute  pleurisy  in  the 
stage  of  effusion  would,  strictly  speaking,  find  here  a  place ;  but 
the  acute  symptoms  bring  it  into  another  class,  with  which  it  has 
been  more  conveniently  described. 

Chronic  pleurisy  is  established  if  the  fluid,  after  an  acute  attack, 
be  not  absorbed,  or  if  an  accumulation  of  liquid  take  place  grad- 
ually, in  consequence  of  subacute  inflammation  of  the  pleura. 
The  disease  has  no  constant  symptoms,  and  is  often  remarkably 
latent :  the  patient  frequently  does  not  remember  to  have  had 
acute  pleurisy.  He  is  not  commonly  troubled  with  much  cough, 
nor  is  the  want  of  breath  so  great  as  might  be  expected  ;  he  is  not 
capable  of  talking  for  any  length  of  time,  or  in  a  loud  voice,  but 
he  does  not  really  suffer  from  dyspncea.  His  general  health  may 
remain  good,  and  no  emaciation  occur.  In  some  persons,  on  the 
other  hand,  the  loss  of  flesh,  the  quickened  pulse,  the  sweats,  the 
paroxysms  of  hectic  fever,  are  so  marked  as  to  produce  a  close 
resemblance  to  the  last  stages  of  tubercular  consumption. 

While  the  differing  symptoms  rather  hide  the  pleurisy  from 
detection,  the  physical  signs  render  it  easy  of  recognition.  These 
signs  have  been  studied  in  describing  the  effusion  in  acute  pleurisy. 
It  is  only  necessary  to  recall  that  the  most  significant  are  absent 
respiration  and  voice,  a  flat  sound  on  percussion,  with  a  vesiculo- 
bronchial or  a  bronchial  respiration  above  the  seat  of  the  liquid. 
The  intercostal  spaces  are  obviously  widened ;  their  depressions 
are  effaced.  They  are,  indeed,  sometimes  convex,  and  the  finger 
pressed  on  them  detects  a  distinct  fluctuation.     During  the  act 

*  Boisseau,  Arch.  Gen.  de  Med.,  vol.  ii.,  1867. 


366  MEDICAL   DIAGNOSIS. 

of  breathing,  the  diseased  side  is  ahiiost  motionless,  presenting  a 
strong  contrast  to  the  obvious  play  of  the  healthy  side.  The  lung 
which  is  not  disturbed  increases  in  size.  Its  murmur  is  more  in- 
tense, sometimes  harsher;  and  the  percussion  sound  over  it  is 
exceedingly  cU'ar.  In  some  cases  it  becomes  emphysematous. 
The  heart  or  liver  is  displaced.  A  lateral  curvature  of  the  spinal 
column  is  apt  to  take  ])lace,  and  the  shoulder  remains  fixed  and 
stiff  during  the  respiratory  acts.  To  distinguish  whether  the  fluid 
is  collected  in  one  cavity  or  in  several,  in  other  words,  whether 
unilocular  or  multilocular,  is  generally  impossible.  Jaccoud  *  has, 
however,  called  attention  to  some  points  >vhieh  aid  in  arriving  at 
a  conclusion.  If  we  have  a  zone  in  the  dulness  where  vocal  vibra- 
tions are  preserved,  as  at  the  posterior  part  of  the  chest  from  along 
the  vertebral  column  toward  the  sternum,  and  beyond  this  zone 
no  vibrations  are  perceived,  we  may  infer  that  the  effusion  is 
divided  by  a  band  of  pleural  adhesion ;  if  the  voice  and  fremitus 
be  preserved,  although  weakened,  over  the  whole  extent  of  the 
dulness,  except  in  a  zone  of  a  few  finger-breadths  at  the  lower 
part  of  the  chest  behind,  Avhile  no  tympanitic  sound  is  elicited 
under  the  clavicle,  we  are  to  conclude  that  the  pleurisy  is  multi- 
locular. When  adhesions  to  the  diaphragm  exist,  the  normal 
movements  during  respiration  at  the  epigastrium  and  hypochon- 
drium  are  reversed,  and  at  each  inspiration  a  marked  depression 
of  the  inferior  intercostal  spaces  is  perceptible. 

Effusions  into  the  pleural  sac  may  last  for  a  long  time,  and 
lead  to  death  by  progressive  exhaustion  ;  or  tlie  patient  may  re- 
cover by  the  fluid  being  absorbed,  or  by  its  finding  a  vent  through 
the  bronchial  tubes  or  the  thoracic  walls.  But  the  chest  is  rarely 
restored  to  its  former  state.  The  lung  was  too  much  compressed, 
or  is  still  bound  down  by  too  firm  adhesions,  to  resume  its  full 
share  in  the  function  of  respiration.  The  walls  of  the  chest  sink 
in  around  it,  and  the  side  is  flattened,  sounds  duller  on  percus- 
sion, and  presents  a  feebler  breathing  than  the  other  lung,  which 
remains  somewhat  enlarged.  The  heart  generally  returns  to  its 
normal  position,  but  the  shoulder  on  the  affected  side  is  apt  to 
show  a  permanent  depression. 

Notwithstanding  the  decided  character  of  the  physical  signs, 

*  Bulletin  de  I'Acadeinie  de  Medecine,  1879. 


DISEASES   OP   THE   LUNGS.  367 

chronic  pleurisy  is  frequently  overlooked.  The  only  explana- 
tion of  this  is,  that  so  little  attention  is  paid  to  the  physical 
signs.  Were  the  chest  more  often  carefully  explored,  we  should 
cease  to  hear  of  patients  whose  pleural  cavity  is  filled  with  pus 
being  pronounced  incurable  consumptives,  because  they  are  emaci- 
ating and  have  hectic  fever  and  clubbed  nails;  or  being  treated 
for  disease  of  the  heart,  on  account  of  the  displacement  of  that 
organ,  and  of  dyspnoea  and  oedema  ;  or  being  dosed  with  mercury, 
for  an  imaginary  disorder  of  the  liver  ;  or  being  subjected  to  long 
courses  of  quinine  and  arsenic,  to  check  a  rebellious  ague  which 
the  chilly  sensations  and  paroxysms  of  fever  at  times  simulate. 

These  physical  signs  are  the  same  whether  the  fluid  be  serum 
or  pus.  The  character  of  the  fluid  produces,  indeed,  no  distinc- 
tive changes  either  in  the  signs  or  in  the  symptoms.  We  suspect 
empyema  if  the  emaciation  be  great  and  accompanied  by  a  quick 
pulse,  high  temperature,  and  hectic  fever ;  but  I  have  known  pus 
in  the  chest  with  a  temperature  scarcely  above  the  norm,  and,  on 
the  other  hand,  the  accumulation  not  to  be  purulent  with  a  tem- 
perature of  103°.  Baccelli  has  proposed  a  new  and  simple  test 
to  determine  the  character  of  the  fluid,  which,  on  the  whole,  I 
believe  to  be  of  use.  It  consists  in  ascertaining  accurately  how 
the  voice  penetrates,  especially  the  whispered  voice.  If  easily  and 
thoroughly  transmitted,  the  liquid  is  serous  and  homogeneous  ;  if 
with  difficulty,  it  is  fibrinous  or  purulent ;  if  not  at  all,  it  is  most 
apt  to  be  the  latter.  In  cases  of  much  doubt  I  have  long  been 
in  the  habit  of  using  a  hypodermic  syringe  and  removing  with  it 
enough  of  the  fluid  for  microscopical  examination.  In  rare  in- 
stances the  fluid  consists  of  fat-globules  and  of  masses  of  choles- 
terine.*  In  cases  of  hemorrhagic  pleurisy  the  hsemoglobinometer 
will  inform  us  accurately  as  to  the  amount  of  blood  in  the 
exudation.! 

When  we  come  to  inquire  into  the  thoracic  diseases  with  which 
chronic  pleurisy  is  likely  to  be  confounded,  we  shall  find  that, 
although  many  have  some  signs  in  common,  few,  if  any,  present 
the  same  association  of  signs.  Leaving  out  the  malady  which  is 
most  commonly  mistaken  for  it, — pulmonary  consumption, — since 

*  Debove,  Soc.  Med.  des  Hopitaux  de  Paris,  tome  xviii.,  1881. 
t  Henry,  Medical  News,  April  14,  1888. 


368  MEDICAL   DIAGNOSIS. 

the  points  of  difference  have  ah'eadv  been  discussed,  the  affeetlons 
with  which  clironic  pknirisy,  while  the  })leiira  is  full  of  liquid 
and  the  chest  enlarged,  is  liable  to  be  confounded,  are  : 

Emphysema  and  Pneumothorax  ; 

Intra-tiioracic  Tumor  ; 

Enlargement  of  the  Liver  ; 

Enlargement  of  the  Spleen  ; 

Abscess  in  the  Thoracic  Walls  ; 

Pericardial  Effusion  ; 

Hydrothorax. 

Emphysema  and  Pneumothorax. — These,  although  such  dif- 
ferent diseases,  are  grouped  together  because  they  give  rise,  like 
chronic  pleurisy,  to  a  dilated  chest,  and  to  displacement  of  the 
liver  or  heart.  But  the  other  signs  above  pointed  out,  which 
indicate  the  presence  of  air,  are  so  striking,  that  an  error  in 
diagnosis  can  only  be  the  result  of  carelessness. 

Intra-thoracic  Tumor. — A  tumor  witliin  the  chest  may  occasion 
the  same  distention  of  its  walls,  the  same  displacement  of  organs, 
the  same  dulness  on  percussion,  and  the  same  absent  respiration,  as 
an  effusion  of  liquid  into  the  pleura  ;  yet  the  signs  are  not  exactly 
alike.  There  is  no  fluctuation  in  the  bulging  intercostal  spaces; 
the  vocal  fremitus  is  not  so  constantly  abolished ;  and  the  level  of 
the  dulness  is  not  changed  by  altering  the  patient's  position.  Nor 
is  the  flat  sound  so  uniform  or  so  strictly  limited  as  that  produced 
by  fluid  :  amid  the  didness  may  be  detected  here  and  there  a  spot 
yielding  on  percussion  a  clear  sound.  A  tumor  in  the  chest,  more- 
over, presses  on  the  nerves,  or  bronchial  tubes,  or  great  vessels, 
and  thus  gives  rise  to  severe  pain,  and  to  dyspnoea  and  signs  of  in- 
terrupted circulation  far  more  evident  than  are  caused  by  a  pleu- 
ritic effusion.  It  not  infrequently  grows  into  the  mediastinum,  and 
then  leads  to  prominence  of  the  sternum,  a  "d  to  dilatation  of  both 
sides  of  the  chest.  These  phenomena  are  found,  whatever  be  the 
nature  of  the  morbid  growth.  As  most  of  the  thoracic  tumors 
are  cancerous,  we  are  often  assisted  in  our  diagnosis  by  discover- 
ing a  cancer  in  other  parts  of  the  body,  and  by  noting  the  severe 
pain  in  the  chest,  the  harassing  cough,  and  the  expectoration  of 
blood,  or  of  a  peculiar  jelly-like  substance.  Yet  these  evidences, 
while  they  aid  us  in  establishing  the  fiict  of  a  morbid  growth  in 
the  thoracic  cavity,  do  not  by  any  means  determine  its  situation. 


DISEASES   OF   THE   LUNGS.  369 

We  cannot  go  a  step  further,  and  say,  with  certainty,  whether  the 
abnormal  formation  be  situated  exclusively  in  the  lung,  or  in  the 
pleura,  or  whether  it  affect  both.  When  the  tumor  occupies  the 
mediastinal  spaces,  and  is  not  cancerous,  it  is  most  likely  a  sar- 
coma. Lymphadenomata  come  next  in  frequency.*  In  children, 
however,  sarcoma  is  a  more  frequent  neoplasm  than  carcinoma. f 

In  those  cases  in  which  an  effusion  into  the  pleura  complicates 
an  intra-thoracic  tumor,  attention  to  the  history  and  to  the  signs 
of  pressure  alone  apprises  us  of  its  presence.  Yet  both  signs  and 
symptoms  may  be  so  closely  like  those  of  chronic  pleurisy  as .  to 
render  a  differential  diagnosis  impossible.  Nay,  friction  sounds, 
a  stitch  in  the  side,  and  fever  may  be  produced  by  a  cancer  of 
the  pleura,  and  be  apparently  so  rapidly  developed  as  to  cause 
the  disease  to  be  regarded  as  an  acute  or  subacute  inflammation  of 
that  membrane.  Cancer  of  the  pleura,  like  tubercle  of  this  struc- 
ture, has,  therefore,  no  pathognomonic  signs.  The  most  certain 
sign  of  cancer  of  the  pleura  is  probably  the  one  mentioned  by 
Trousseau,p.'.iamely,  that  the  fluid  which  is  evacuated  by  paracen- 
tesis consists  of  a  bloody  serum.  EhrlichJ  has  published  seven 
cases,  in  three  of  which  he  found  special  cellular  elements  in  the 
fluid,  and  was  thus  enabled  to  come  to  a  correct  conclusion.  In 
some  instances,  however,  there  is  no  fluid  in  a  greatly-thickened 
cancerous  pleura. § 

It  is  at  times  equally  impossible  to  distinguish  a  circumscribed 
pleurisy  from  a  tumor  in  the  chest.  In  those  rare  cases  in  which 
adhesions  bound  the  liquid  effusion  and  encyst  it,  we  observe  all 
the  marks  of  a  tumor, — a  restricted  bulging  and  percussion  dul- 
ness,  and  an  absent  respiration.  Several  cysts  may  form  as  the 
result  of  successive  attacks  of  pleurisy,  and  may  exist  at  any  por- 
tion of  the  chest.  The  fluid  may  be  collected  in  the  mediastinum, 
or  between  the  lobes  of  the  lung,  or  anywhere  between  the  surfaces 
of  the  pleural  membrane.  The  purulent  contents  of  the  sac  some- 
times find  their  way  into  the  bronchial  tubes,  and  are  expectorated, 
or  give  rise  to  a  distinct  fluctuation  in  the  intercostal  spaces,  and 
then  discharge  through  the  thoracic  parietes.     In  such  cases  the 

*  Hobart  A.  Hare,  Affections  of  the  Mediastinum,  1889. 
t  Edwards,  Archives  of  Pediatrics,  Julj^,  1889. 
X  Charite  Annalen,  1882. 

I  Puijesz,  Deutsches  Archiv  f.  Klin.  Med.,  Aug.  1883. 
24 


370  IMEDICAL    DIAGNOSIS. 

diagnosis  is  not  difficult.  But  Avhere  these  phenomena  are  not 
present,  the  dissimilar  history  of  the  case  and  the  absence  of 
symptoms  of  pressure  arc  the  only  means  of  distinction  IVum  a 
tumor  in  the  chest.  Fortunately,  encysted  ])leurisy  is  a  rare 
disease;  were  it  frequent,  it  would  be  a  fruitful  source  of  error. 
The  same  remark  applies  to  hydatid  cysts,  which  may  occasion  all 
the  signs  of  a  circumscribed  pleurisy.*  An  examination  of  the 
fluid  obtained  by  an  exploratory  puncture,  in  which  echinoeocci 
are  found,  is  the  only  positive  test. 

Enku'cjement  of  the  Liver, — An  enlarged  liver  nsually  descends 
into  the  abdominal  cavity ;  yet  it  may  be  forced  upward  as  far  as 
the  fourth  rib,  and,  by  encroaching  upon  the  lung,  may  give  rise 
to  many  of  the  physical  signs  of  a  pleuritic  effusion.  The  surest 
diagnostic  test  is,  that  during  full  inspiration  and  expiration  the 
line  of  dulness  descends  and  ascends ;  while  the  flat  sound  of  a 
plenritic  effusion  is  not  affected  by  the  play  of  the  lungs.  This 
test  will  be  applicable  except  where  the  liver  is  firmly  adherent 
to  the  walls  of  the  abdomen.  As  circumstances  to  assist  in  dis- 
criminating between  the  enlargement  of  the  abdominal  organ 
and  the  presence  of  liquid  in  the  chest,  may  be  mentioned  that 
the  heart,  if  at  all  displaced,  is  pushed  upward,  and  not  toward 
the  side ;  and  that  the  dulness  of  an  enlarged  liver  extends  higher 
up  anteriorly  than  posteriorly,  which  is  the  reverse  of  what  takes 
place  in  a  pleuritic  effusion.  Moreover,  the  respiration  at  the 
lower  portion  of  the  lung  posteriorly,  although  enfeebled,  is  still 
audible. 

Enlargement  of  the  Spleen. — An  enlarged  spleen  is  attended 
with  prominence  and  with  dulness  on  percussion  at  the  lower 
part  of  the  chest  on  the  left  side,  and  might,  therefore,  mislead 
into  the  idea  of  a  pleuritic  effusion.  Error  in  diagnosis  is  pre- 
vented  bv   attention   to  the  fact  that  the  dulness  extends  also 


*  See  the  observations  of  Vigla,  Arch.  Gen.  de  Med.,  Sept.  and  Nov.  1855, 
and  of  Eoger,  ib.,  Nov.  1861 ;  also  cases  quoted  in  Schmidt's  Jahrb.,  No.  10, 
1869,  and  in  London  Lancet,  July,  1871,  where  they  are  stated  to  be  fre-. 
quent  in  Australia  ;  also  experiences  of  Bird,  ib.,  March,  1877  ;  Lebert's  Klinik 
der  Brustkrankheiten,  Bd.  ii.  ;  P.  Kidd,  Transact.  Pathol.  Soc,  London, 
1884-85,  xxxvi.;  C.  Hochsingcr,  Wien.  Med.  Bliitt.,  1887,  x.  ;  J.  D.  Thomas, 
Australasian  Jledical  Gazette,  1887-88,  vii.  ;  L.  Bard  and  R.  Chabannes,  Eev. 
de  Med.,  Paris,  1888,  viii. 


DISEASES    OF    THE    LUNGS,  371 

downward  and  toward  the  median  lino.  Again,  the  heart  is  not 
laterally  displaced,  but  tilted  upward ;  the  respiration  is  feeble, 
but  not  absent;  and  the  vocal  vibrations  are  mostly  unimpaired. 

Abscess  in  the  Thoracic  Walls. — This,  too,  leads  to  local  tume- 
faction and  fluctuation  ;  but  we  can  ascertain  whether  a  fluctuating 
tumor  in  the  intercostal  spaces  communicates  with  the  pleural  cav- 
ity or  not — whether,  in  other  words,  it  is  or  is  not  the  result  of  an 
eifusion  which  is  pointing  externally — by  watching  how  pressure 
and  the  acts  of  respiration  affect  it.  For,  unless  the  diaphragm 
has  become  immovable  from  the  extent  of  the  effusion,  a  bulging 
which  is  in  connection  with  the  pleura  is  diminished  during  a  full 
inspiration,  and  becomes  more  prominent  when  the  diaphragm 
ascends  in  expiration.  The  swelling,  moreover,  can  be  made  to 
disappear  to  some  extent  by  pressure.  It  is  not  so  with  an  ab- 
scess seated  in  the  walls  of  the  chest.  It  is  not  reducible,  and 
does  not  recede  during  inspiration. 

Pericardial  Effusion. — An  eifusion  into  the  pericardium  ought 
not  to  be  mistaken  for  an  effusion  into  the  pleura.  The  first  in- 
duces prominence  and  increased  dulness  on  percussion  over  the 
regipn  of  the  heart ;  the  second,  dulness  and  prominence  over  the 
back  part  as  well  as  over  the  front  of  the  lung.  A  few  cases  are, 
however,  recorded  in  which  an  enormously-distended  pericardial 
sac  produced  a  flat  sound  posteriorly,  and  gave  rise  to  signs  of 
compression  of  the  lung.  But  in  these  attention  to  the  feeble 
impulse  of  the  heart  and  its  muffled  sounds  permitted  it  to  be 
foretold  that  fluid  had  accumulated  in  the  pericardium,  and  not 
in  the  pleura. 

Hydrothorax. — A  dropsy  having  its  seat  in  the  pleural  cavity  is 
called  hydrothorax,  or  water  on  the  chest.  The  term  is,  in  truth, 
sufficiently  significant,  the  fluid  which  is  poured  out  being  very- 
thin  and  watery.  The  physical  signs  of  hydrothorax  are  the 
same  as  those  of  an  effiision  due  to  inflammation ;  but,  as  the 
dropsy  results  from  an  organic  disease  of  the  liver,  heart,  or  kid- 
neys, the  serum  collects  in  both  pleural  sacs.  ]S'ow,  an  effiision 
caused  by  an  inflammation  of  the  pleura  is  nearly  always  one- 
sided. Even  where  both  pTeurse  are  filled  with  fluid, — a  rare 
condition,  except  in  tubercular  pleurisy, — one  is  affected  before 
the  other.  This  does  not  happen  in  hydrothorax.  Thus  the 
double-sided  effusion,  and  its  usual  association  with  dropsies  in 


372  MEDICAL   DIAGNOSIS. 

other  parts  of  tlie  body,  arc  matters  of  much  significance.  Be- 
sides, in  forming  a  diagnosis  of  hvdrothorax  we  may  lay  some 
stress  on  the  absence  of  friction  sounds ;  on  the  smaller  quantity 
of  fluid ;  on  the  history  of  the  malady ;  and  on  the  presence  of  a 
structural  lesion  of  the  liver,  kidneys,  or  heart. 

These,  then,  are  the  diseases  with  which  chronic  pleurisy,  when 
it  produces  dilatation  of  the  chest,  may  be  confounded.  Indeed, 
in  view  of  the  frequency  of  the  operation  of  aspiration  or  of  para- 
centesis, it  is  important  to  know  what  affections  besides  chronic 
pleurisy  ma}"  lead  to  prominence  of  the  chest  and  to  compression 
of  the  lung ;  and  tapping  the  chest  has  in  itself  certain  diagnostic 
bearings  which  may  be  here  alluded  to.  One  of  these  is  an  albu- 
minous expectoration  that  follows,  which  may  be  looked  upon  as 
a  passing  albuminuria  due-  to  circulatory  disturbances.  It  is  not 
an  unfavorable  event ;  on  the  contrary,  in  cases  in  which  it  hap- 
pens, retraction  of  the  thoracic  parietes  is  less  likely  to  occur.* 

Diseases  in  which  Ketraction  of  the  Chest  occurs. 

Chronic  Pleurisy. — We  may  here  continue  the  description 
of  chronic  pleurisy  in  the  stage  of  absorption,  since  it  is  under 
these  circumstances  that  the  most  marked  retraction  of  the  walls 
of  the  chest  takes  place.  This  shrinking  of  the  thoracic  parietes 
is  not  a  sudden,  but  a  gradual  act,  and  instances  are  therefore  con- 
stantly met  with  in  which  the  upper  part  of  the  chest  is  flattened 
and  the  lower,  owing  to  its  still  containing  fluid,  bulges.  The 
contraction  of  one  side  of  the  thorax  attains  its  highest  degree 
when  the  effusion  in  the  pleura  is  discharged  through  the  chest- 
walls  and  external  fistulous  openings  are  established. 

The  symptoms  in  the  stage  of  retraction  are  those  of  chronic 
pleurisy  with  dilatation  of  the  chest,  and  present,  therefore,  the 
same  variableness.  But  oedema  of  the  affected  side,  which  is  some- 
times so  striking  a  symptom  of  chronic  pleurisy  when  the  effusion 
is  considerable,  is  here  not  noticed.  The  physical  signs  alter 
somewhat,  according  to  the  presence  or  absence  of  fluid  in  the 
pleural  sac.  When  none  exists,  respiration  is  lieard  all  over  the 
lung  as  a  feeble  inspiration  with  prolonged  expiration,  or  as  an 
mdistinct  blowing ;  and  now  and  then  a  friction  sound  may  be 

*  Legroux,  Arch.  Gen.  de  Med.,  Auq-.  1873. 


DISEASES   OF   THE   LUNGS.  373 

caught.  When  the  pleura  still  contains  liquid,  these  signs  occur 
at  the  upper  portion  of  the  chest,  and  a  much  more  absolute  dul- 
ness  on  percussion,  an  absent  voice  and  vocal  fremitus  at  the  lower 
part  denote  that  fluid  has  there  accumulated.  The  heart  is  found 
either  in  its  normal  position  or  still  displaced.  The  force  with 
which  contraction  takes  place  may  pull  it  over  to  the  side  on 
which  the  shrinking  is  going  on. 

Now,  it  is  evident  that  chronic  pleurisy,  when  leading  to  re- 
traction of  one  side  of  the  chest,  cannot  be  mistaken  for  diseases 
attended  with  thoracic  distention ;  but  it  may  be  mistaken  for 
affections  like  pulmonary  cancer,  tubercle,  and  chronic  consolida- 
tion, which  also  occasion  a  flattening  of  the  chest-walls. 

From  cancer  we  distinguish  it  by  the  absence  of  the  peculiar 
expectoration,  and  of  hemorrhage ;  by  the  want  of  signs  of  per- 
fect-consolidation ;  and  by  the  dissimilar  history.  We  distinguish 
it  from  tubercle  by  the  diminution  of  the  chest  in  the  latter  not 
being  confined  to  one  side ;  by  the  physical  signs  indicative  of 
deposit  and  softening  at  the  upper  portions  of  the  lungs ;  by  the 
presence  of  rales ;  by  the  occurrence  of  hemorrhage ;  and  by  the 
greater  emaciation. 

Chronic  pneumonic  consolidation  presents,  on  the  whole,  most 
points  of  resemblance.  But  there  is  this  difference  :  the  shrinking 
of  the  side  in  chronic  pneumonia  is  less  marked,  and  is  confined 
to  the  part  involved, — usually  the  lower  lobe  of  the  lung.  The 
retraction  is  much  more  general  in  chronic  pleurisy ;  or  where 
it  is  partial,  it  is  the  upper  segment  of  one  side  of  the  chest 
which  is  flattened, — the  lower  is  prominent,  and  sounds  very  dull 
on  percussion,  shows  no  change  on  respiratory  percussion,  and 
yields  the  ordinary  physical  evidences  of  fluid.  In  the  former 
malady  the  blowing  respiration,  or  the  enfeebled  inspiration  and 
prolonged  expiration,  and  the  distinct  voice  are  heard  only  over 
the  consolidated  lobe ;  in  the  other  lobes  the  breathing  is  plainly 
vesicular.  In  chronic  pleurisy  the  same  abnormal  signs,  except 
perhaps  the  increased  voice,  are  either  manifest  over  an  entire 
side,  or  they  are  perceived  over  the  narrowed  portion  of  the  chest, 
and  at  the  lower  part  the  respiration,  voice,  and  fremitus  are 
abolished. 

In  that  form  of  chronic  pulmonary  induration  attended  com- 
monly with  dilatation  of  the  bronchial  tubes,  to  which  the  name 


0<4  MEDICAL    DIAGNOSIS. 

of  cirrhosii<  of  the  liino;,*''or  fibroid  phthisis,  has  been  given,  the 
flattening-  of  the  atfeeted  side  is  as  obvions  as  it  is  in  pleurisy. 
In  truth,  the  two  disorders  bear  a  strong  reUition  to  each  .other. 
The  increased  formation  of  connective  tissue  in  the  pleuritic  ad- 
hesions passes  on  into  the  lung,  occasioning  an  interstitial  pneu- 
monia,— though  the  fibroid  change  may  begin  in  the  lung, — and, 
as  tliis  progresses  and  the  lung  shrinks,  bronchial  dilatations  usu- 
ally follow.  We  distinguish  cirrhosis  of  the  lung  by  the  copious 
and  peculiar  sputum  which  attends  the  bronchial  affection  ;  by  the 
rales ;  by  the  harsh  or  bronchial  or  tubular  or  feeble  respiration  ; 
by  the  dulness  on  percussion  with  an  occasional  tympanitic  note ; 
by  the  marked  resistance  of  the  chest-A\alls ;  by  the  increased  vocal 
resonance ;  by  the  narrowing  of  the  intercostal  spaces ;  and  by  the 
displaced  apex  beat, — forced  up,  if  the  disorder  be  on  the  left  side, 
one  or  several  intercostal  spaces,  or  so  covered  by  the  expanded 
left  lung,  if  the  disorder  be  on  the  right,  as  to  be  imperceptible, 
unless  the  shrinking  of  the  aifected  lung  be  considerable,  when 
the  heart  may  be  found  drawn  over  on  the  diseased  side.  Fur- 
ther signs  of  the  complaint,  when  the  malady  is  left-sided,  are 
that  in  the  second  intercostal  space  to  the  left  of  the  sternum  a 
double  beat  of  the  pulmonary  artery  is  perceptible,  and  that 
whichever  side  is  diseased  shows  the  diaphragm  greatly  displaced 
upward,  and  a  marked  vesicular  resonance  in  a  line  along  the 
edge  of  the  sternum  caused  by  the  overlapping  of  the  healthy 
limg,  and  in  strong  contrast  with  the  line  of  dulness  of  the  cir- 
rhosed  organ. f  The  affection  is  a  very  chronic  one,  and  unat- 
tended with  fever  or  laryngeal  symptoms.  Loss  of  flesh  and  of 
strength  is  very  gradual,  and  night-sweats  are  slight  or  incon- 
stant. Dilatation,  or  hypertrophy  with  dilatation,  of  the  right  side 
of  the  heart,  and  dropsy,  are  not  infrequent,  and  haemoptysis  is  still 
oftener  met  with.  The  disease  has  among  its  causes  the  inhalation 
of  fine  particles,  such  as  of  steel,  of  coal-dust,  of  cotton.  It  may 
have  an  obscure  beginning,  or  it  may  clearly  date  from  an  acute 
catarrhal  pneumonia  or  plastic  pleurisy.  It  very  rarely  becomes 
complicated  with  tubercle.  The  fibroid  condition  of  the  lungs — 
also  called  by  some  fibroid  phthisis — in  old  tubercular  lungs  or 


*  Corrigan,  Dublin  Quart.  Jourii.,  vol.  xiii. 

f  Nothnagel,  Sammlung  Klinischer  Vortrage,  1874. 


DISEASES   OF   THE   LUNGS.  375 

around  cavities  is  an  evidence  ratlier  of  a  disposition  toward 
healing,  and  is  not  the  disease  under  consideration.  Pidnionary 
cirrhosis  often  proves  fatal  from  an  acute  affection,  a  bronclio- 
pneumonia  or  a  pneumonia,  of  the  previously  healthy  lung.  In 
very  rare  instances  it  is  double.* 

A  collapsed  state  of  the  lung,  resulting  from  a  plug  of  mucus 
in  the  bronchial  tubes,  may,  in  rare  instances,  yield  the  mani- 
festations of  chronic  pleurisy  with  partial  retraction.  ]N"o  signs 
distinguish  such  cases,  except  the  more  limited  depression ;  the 
absence  of  any  disease  above  the  flattened  spot;  the  want  of 
friction  sound,  and  of  tenderness  on  pressure ;  and  the  rapid  dis- 
appearance of  the  physical  phenomena  after  an  effort  of  coughing 
has  removed  the  obstruction. f 

Where  external  fistulous  openings  exist,  the  shrinking  of  the 
side,  as  already  stated,  is  carried  to  the  highest  degree.  These 
fistulse,  whether  produced  artificially  or  by  nature,  may  close  after 
they  have  served  the  purpose  of  evacuating  the  fluid  in  the  pleural 
cavity.  But  they  often  persist  for  months  or  years,  and  keep  on 
discharging  offensive,  purulent  matter.  The  patient  emaciates 
under  this  continued  drain,  yet  not  so  quickly  as  might  be  im- 
agined. More  or  less  troublesome  cough  annoys  him,  but  it  is  not 
ordinarily  accompanied  by  much  expectoration.  Every  now  and 
then,  however,  he  discharges  for  days  a  quantity  of  fetid,  purulent 
sputum.  It  is  difficult  to  understand  why  this  happens.  It  seems 
certainly,  as  far  as  physical  signs  can  prove,  not  the  liquid  in  the 
pleura  which  is  being  voided  through  a  perforation  of  the  pulmo- 
nary tissue,  for  the  physical  signs  of  pneumothorax  are  absent. 

The  clubbing  of  the  nails  is  often  extremely  marked,  and 
may  exist  to  an  extent  far  greater  than  in  phthisis.  The  nail  is 
rounded  and  bluish,  and  the  whole  end  of  the  finger  looks  en- 
larged. This  appearance  is  even  more  striking  than  the  curve 
of  the  nail.  The  nails  and  last  joints  of  the  toes  show  the  same 
alteration. 

The  fistulous  opening  is  situated  ordinarily  in  the  intercostal 
space  below  the  nipple.     It  may,  however,  be  seated  at  the  back 


*  McCoUom,  New  York  State  Med.  Assoc,  1885. 

f  An  interesting  instance  of  this  kind  is  related  by  Prof.  William  Pepper 
the  elder  in  the  American  Journal  of  the  Medical  Sciences  for  April,  1852. 


376  MEDICAL   DIAGNOSIS. 

of  the  chest,  and  eommiiiiieate  bv  a  tortuous  sinus  witli  the  intes- 
tine and  other  abdominal  viscera.  If  it  pass  into  the  lung,  the 
physical  evidences  of  pneumothorax  are  present,  but  the  side  is 
still  retracted,  and  striking-  the  chest  elicits  a  mixture  of  a  dull 
and  a  tympanitic  sound.  Where  merely  an  external  opening 
exists,  no  signs  of  pneumothorax  occur,  because  no  air  finds  its 
way  into  the  pleural  cavity. 

A  fistulous  opening  into  the  pleura  is  not  difficult  of  diagnosis. 
It  is  easy  to  establish  the  fact  that  the  fistula  is  not  simply  pro- 
duced by  caries  of  the  rib ;  for  a  probe  may  be  run  into  the  chest 
for  two,  three,  or  four  inches. 

I  base  these  statements  on  a  number  of  instances  of  chronic 
pleurisy  attended  with  external  fistula  which  have  come  under 
my  notice.  The  seat  of  the  opening  near  the  nipple  ;  the  peculiar 
nail ;  the  occasional  flow  for  days  of  a  most  offensive  sputum 
from  the  bronchial  tubes,  without  any  traces  of  pneumothorax ; 
the  ease  with  which  the  fistula  could  be  probed,  and  its  depth ; 
the  gradual  emaciation ;  and,  I  may  add,  the  decided  improve- 
ment under  the  persistent  use  of  cod-liver  oil  and  tonics, — be- 
longed to  them  all,  and  justify  the  description  given. 


SECTION  II. 

DISEASES   OF   THE   HEART. 

The  heart,  is  kept  from  rolling  about  in  the  chest  by  the  great 
vessels  which  spring  from  its  base,  and  by  the  attachment  to  the 
diaphragm  of  its  membranous  covering, — the  pericardium.  It 
lies  obliquely  in  this  membrane,  with  its  long  axis  directed  down- 
ward and  toward  the  left.  Its  base  points  backward  and  upward 
toward  the  right  shoulder ;  its  under  side  rests  upon  the  central 
tendon  of  the  diaphragm.  The  interior  of  the  heart  is  lined  by  a 
serous  membrane, — the  endocardium, — which  is  reflected  over  the 
valves.  These  valves  all  lie  in  close  proximity  to  one  another, 
and  within  a  space  of  less  than  an  inch  square. 

The  relations  the  different  parts  of  the  organ  bear  to  the  chest- 


DISEASES   OP   THE   HEART. 


377 


walls  are  as  follows.  The  auricles  are  on  a  line  with  the  third 
costal  cartilages ;  the  right  auricle  extends  across  the  sternum  to 
the  right  side  of  the  chest.  The  right  ventricle  is  placed  partly 
under  the  sternum,  and  partly  to  the  left  of  it.  Its  inferior  bor- 
der is  on  a  level  with  the  sixth  cartilage.     The  left  ventricle  lies 

Fig.  32. 


Topography  of  the  heart.  The  relations  of  each  portion  of  the  heart  to  the 
walls  of  the  chest  are  shown.  The  dotted  lines  mark  the  lungs.  The  figure 
is  based  upon  several  careful  dissections. 


within  the  nipple,  between  the  third  and  fifth  intercostal  spaces. 
The  apex  is  seated  between  the  cartilages  of  the  fifth  and  sixth 
ribs,  to  the  inner  side  of,  and  from  an  inch  and  a  half  to  two 
inches  below,  the  left  nipple.  The  base  of  the  heart  corresponds 
posteriorly  to  the  sixth  and  seventh  dorsal  vertebrae,  from  which 
it  is  separated  by  the  aorta  and  oesophagus.  The  greater  portion 
of  the  anterior  surface  of  the  heart  is  removed  from  the  thoracic 
walls  by  the  lungs.  The  right  lung  extends  to  the  middle  of  the 
sternum.  The  left  lung  spreads  out  as  far  as  the  fourth  cartilage, 
and  covers  the  whole  of  the  left  ventricle,  except  the  apex.     The 


378  MEDICAL    DIAGNOSIS. 

part  of  the  heart  which  remains  exposed  consists  thns  mainly  of 
the  lower  portion  of  the  right  ventricle ;  it  presents  the  shape  of 
a  rude  triangle. 

The  position  of  the  valves  can  be  learned  by  running  needles 
into  the  chest  before  the  viscus  is  taken  out.  In  this  manner  it  is 
ascertained  that  at  the  left  border  of  the  sternum,  on  a  level  M'ith 
the  third  intercostal  space,  lies  the  mitral  valve,  and  in  front  of 
this,  more  directly  under  the  sternum,  and  but  a  few  lines  lower, 
the  tricuspid  valve.  The  pulmonary  orifice  is  seated  opposite  the 
junction  of  the  cartilage  of  the  third  rib  with  the  left  edge  of  the 
sternum.  Xear  it,  very  slightly  lower,  but  placed  more  obliquely, 
are  the  aortic  valves.  The  aorta  then  proceeds  fi'om  left  to  right, 
and  ascends  to  the  upper  border  of  the  second  costal  cartilage  on 
the  rig\[it  side;  thence  it  crosses,  under  the  sternum  and  in  front 
of  the  trachea,  to  the  left  side.  The  pulmonary  artery  is  found 
in  the  second  intercostal  space  on  the  left  side,  enclosed  in  the 
pericardium,  and  passes  to  the  cartilage  of  the  second  rib,  where 
it  bifurcates. 

The  size  of  the  heart  is  about  that  of  the  closed  fist.  Its  mean 
weight  in  adults  is  between  eight  and  nine  ounces.  Only  in  very 
large  persons  does  it  exceed  this. 

The  organ  exhibits,  when  in  action,  a  wonderfully  perfect  mech- 
anism and  regularity  of  movement.  Its  cavities  contract  on  both 
sides  at  the  same  time,  and  distend  on  both  sides  at  the  same 
time.  It  then  rests  for  a  short  period.  The  contraction  of  the 
ventricles  occasions  the  impulse  which  is  seen  and  felt  in  the  fifth 
intercostal  space.  While  the  blood  is  flowing  in  and  out  of  the 
heart,  the  valves  are  kept  in  constant  motion.  Their  play  makes 
itself  known  by  two  distinct  sounds  of  unequal  length,  which  are 
produced  mainly  by  their  opening  and  closing. 

The  first  sound,  long  and  dull,  is  caused  by  the  forcible  closure 
of  the  valves  at  the  auriculo- ventricular  openings.  Yet  it  is  not 
a  purely  valvular  sound.  The  stroke  of  the  heart  against  the 
walls  of  the  chest,  the  muscular  contraction  itself,  and  the  flow 
of  blood  into  the  aorta  and  the  pulmonary  artery  aid  in  its  for- 
mation. The  first  sound  corresponds,  therefore,  to  the  closure 
of  the  auriculo-ventricular  valves,  to  the  impulse  of  the  heart,  to 
the  opening  of  the  valves  at  the  orifice  of  the  aorta  and  of  the 
pulmonary  artery,  and  to  the  passage  of  blood  along  the  arteries. 


DISEASES   OF   THE   HEART.  379 

The  second  sound  is  short,  abrupt,  and  ringing.     It  results  from 
the  sudden  closure  of  the  semilunar  valves.     During  its  occur- 
rence the  blood  rushes  through  the  opened  mitral  and  tricuspid 
#     valves,  and  dilates  the  ventricles. 

Examination  of  the  Heart  by  the  Different  Methods  of 
Physical  Diagnosis. 

Before  proceeding  to  examine  the  heart,  we  inquire  into  the 
history  of  the  case,  and  into  such  symptoms  as  the  expression 
of  the  face;  the  appearance  of  the  eye;  the  condition  of  the 
capillary  circulation ;  the  presence  or  absence  of  dropsical  swell- 
ings and  of  cough ;  the  state  of  the  breathing ;  the  character  of 
the  pulse;  and  the  frequency  and  violence  of  the  palpitations. 
The  cardiac  region  is  then  scrutinized  by  the  eye  and  by  the 
hand ;  the  size  of  the  organ  is  estimated  by  percussion ;  and, 
lastly,  its  sounds  are  studied  by  the  stethoscope.  These  different 
methods  are  most  conveniently  practised  when. the  patient  is  in  an 
easy  position,  leaning  back  in  a  chair  or  propped  up  with  pillows 
in  bed.     To  examine  them  more  in  detail : 

INSPECTION. 

Inspection  detects  on  the  chest  of  some  healthy  persons  a  slight 
protrusion  over  the  seat  of  the  heart ;  yet  this  is  far  from  being 
constant  or  even  the  general  rule.  When  the  heart  is  hyper- 
trophied,  or  when  fluid  has  accumulated  in  the  pericardium,  we 
perceive  a  marked  prominence  in  the  prsecordial  region.  A  de- 
pression at  the  lower  part  of  this  region  may  be  natural ;  a  very 
evident  depression  is  almost  always  the  result  of  an  attack  of 
pericardial  inflammation. 

Yet  neither  prominence  nor  depression  is  a  very  important  sign. 
One  much  more  so,  which  inspection  shows,  is  the  imjnilse  of  the 
heart.  This  is  seen  where  the  apex  beats  against  the  walls  of  the 
chest :  between  the  fifth  and  sixth  ribs,  about  an  inch  inward  from 
the  nipple  and  two  inches  downward.  It  is  for  the  most  part 
confined  to  this  point,  and  appears  as  a  brief  raising  of  the  integ- 
ument, occurring  with  great  regularity  of  succession.  In  lean 
persons  it  is' very  distinct ;  in  fat  persons  it  is  generally  not  at  all 
perceptible.  Its  seat,  even  in  those  who  are  in  perfect  health,  is 
not  always  exactly  the  same.    It  is  changed  by  different  positions, 


380  MEDICAL   DIAGNOSIS. 

and  by  the  distention  of  the  stomach  after  a  full  meal  or  by  flat- 
ulence. If  is  most  modified  by  the  acts  of  respiration.  During 
a  long-drawn  inspiration  the  heart  descends  somewhat  and  the 
expanded  lung  sweeps  it  inward,  and  the  impulse  becomes  dis- 
cernible in  the  epigastrium.  During  a  fixed  expiration  the  beat 
moves  upward,  and  appears  more  extended  and  weightier.  The 
changes  produced  in  its  situation  by  disease,  both  thoracic  and  ab- 
dominal, are  many.  It  is  tilted  upward  and  outward  by  the  left 
lobe  of  an  enlarged  liver.  It  is  displaced  by  diverse  affections  of 
the  lungs  and  pleura.  It  is  forced  up  by  a  pericardial  effusion. 
It  is  visible  lower  down  and  over  a  larger  surface  in  enlargements 
of  the  heart ;  but  even  then  it  is  most  distinct  at  the  apex.  The 
apex  beat  lies  without  the  line  of  the  nipple  in  most  children  up 
to  the  fourth  year.* 

The  alterations  in  the  character  and  force  of  the  impulse  are 
as  diversified  as  those  of  its  seat.  But  they  are  more  readily 
appreciated  by  the  hand  than  by  the  eye. 

PALPATION. 

Palpation  is,  so  far  as  the  exploration  of  the  heart  is  concerned, 
much  preferable  to  inspection.  Many  an  impulse  can  be  felt  which 
cannot  be  seen.  The  rhythm  of  the  motion  is  changed  by  a  large 
number  of  cardiac  affections,  both  functional  and  organic.  So  are 
the  extent  and  force  of  the  beat.  Both  are  temporarily  increased 
by  powerful  excitement ;  both  are  permanently  augmented  by 
hypertrophy.  In  dilatation  and  pericardial  effusion,  the  extent 
over  which  the  stroke  is  felt  is  greater  than  in  health ;  but  the 
impulse  is  feeble,  and  in  the  latter  disease  irregular  and  wavy. 
Softening  of  the  texture  of  the  heart,  diseases  of  the  brain,  some 
morbid  states  of  the  blood,  and  a  low  condition  of  the  system  will 
also  enfeeble  the  beat. 

The  hand,  when  laid  on  the  prsecordial  region,  perceives  at 
times  two  impulses.  This  double  impulse  is  often  recognizable  in 
health,  especially  in  thin  persons.  It  becomes  still  more  evident 
in  hypertrophy  with  dilatation  of  the  ventricles.  One  of  the  beats 
is  systolic  ;  the  other  corresponds  to  the  diastole.     Bouillaud  cites 

*  J.  Mitchell  Bruce,  Enlargement  of  the  Heart,  in  Keating's  Cyclopaedia 
of  the  Diseases  of  Children,  vol.  ii. 


DISEASES    OF    THE    HEART.  381 

examples  in  which  the  diastolic  stroke  was  double.  The  systolic 
beat  is  occasionally  split  into  several  parts  when  the  pericardium 
adheres  to  the  heart. 

All  these  modifications  of  the  impulse  stand  in  direct  connection 
with  the  action  of  the  ventricles.  The  auricles,  save  in  some  rare 
instances  in  which  they  are  dilated  and  their  walls  thickened,  give 
rise  to  no  perceptible  movement  in  the  chest- wall. 

Besides  the  impulse  of  the  heart,  other  phenomena  may  be 
studied  by  placing  the  hand  over  the  cardiac  region.  The  sounds 
of  the  heart  can  be  analyzed  by  means  of  the  touch.  They  will 
be  felt,  the  one  as  a  long  and  dull,  the  other  as  a  short  and  dis- 
tinct, vibration.  The  motion  is  due  to  the  play  of  the  valves,  and 
disappears  with  their  destruction.  The  fingers  applied  over  the 
heart  perceive  at  times  a  peculiar  thrill,  or  a  rubbing  movement. 
The  first — called  by  Laennec,  from  its  resemblance  to  the  purr 
of  a  cat,  the  purring  tremor — is  nearly  always  indicative  of  a 
valvular  lesion.  The  second  is  caused  by  the  to-and-fro  motion 
of  a  roughened  pericardium. 

A  more  accurate  means  of  studying  the  varying  impulse  than 
is  aiforded  by  the  fingers  has  been  sought  to  be  attained  by  instru- 
ments which  record  the  beat  of  the  heart.  The  cardioscope  of 
Alison  and  the  cardiograph  of  Marey  have  been  used  for  the  close 
analysis  of  the  cardiac  impulse.  But  as  yet  these  instruments 
have  not  proved  to  be  of  any  marked  diagnostic  value. 

PERCUSSION. 

Percussion  affords  the  readiest  means  of  judging  of  the  size  of 
the  heart.  The  patient  is  placed  in  a  recumbent  position ;  then, 
by  a  series  of  moderately  strong  taps,  we  proceed  downward  from 
near  the  middle  of  the  left  clavicle,  until  a  dull  sound,  accompanied 
by  decided  resistance,  tells  that  we  are  striking  over  a  solid  organ. 
The  point  at  which  this  dull  sound  begins  is  over,  or  immediately 
at  the  lower  border  of,  the  fourth  cartilage.  It  corresponds  to  the 
upper  limit  of  the  portion  of  the  heart  which  is  left  uncovered 
by  the  lung. 

The  superior  border  of  the  dulness  having  been  thus  ascer- 
tained, we  next  percuss  on  the  right  side  of  the  sternum,  on 
about  a  level  with  the  fifth  rib,  and  progress  across  the  bone. 
At,  or  very  near  to,  its  left  edge  we  find  marked  resistance  and 


382  MEDICAL    DIAGNOSIS. 

a  duller  sound.  Here  we  draw  our  second  line,  and  continue  to 
strike  straight  across  the  cardiac  region  up  to  the  point  at  which  a 
clear,  full  note  demonstrates  that  the  pulmonary  tissue  is  resound- 
ing. This  determines  the  transverse  diameter  of  the  heart, — at 
least  so  far  as  it  can  be  mapped  out  on  the  chest.  The  ajiex  of 
the  organ  and  its  inferior  surface  remain  to  be  fixed.  The  first  is 
readily  done  by  advancing  in  an  oblique  direction  from  the  already 
ascertained  right  border.  But  we  can  save  ourselves  this  trouble 
by  feeling  for  the  impulse  or  by  listening  for  it  with  a  stethoscope. 
The  inferior  surface  can  be  circumscribed  by  prolonging  the 
line  of  the  dulness  on  percussion  of  the  U2:)per  border  of  the  liver, 
and  then  judging  by  the  greater  amount  of  resistance  and  the 
fall  in  pitch  that  the  heart  has  been  reached.  These  are  not 
easv  to  appreciate ;  nor  is  it  indeed  often  necessary  .to  define  the 
contiguous  edges  of  the  left  lobe  of  the  liver  and  of  the  heart. 
If  the  other  boundaries  have  been  correctly  drawn,  the  size  of  the 
heart  can  be  accurately  estimated, — accurately  enough,  at  least, 
for  any  practical  purpose.  The  dulness  elicited  by  jjercussing  the 
cardiac  region  is  not  so  absolute  as  that  of  the  liver  or  of  some 
other  solids.  It  is  mixed  with  the  sound  of  the  lung-tissue,  or 
with  the  resonance  of  the  sternum,  Xor  is  it  a  representation  of 
the  size  of  the  entire  organ.  It  simply  portrays  the  more  super- 
ficial portion,  which  is  uncovered  by  the  lungs. 

In  women  it  is  particularly  difficult  to  define  these  limits.  It 
can  be  done  only  by  having  the  mammary  gland  drawn  to  one  side 
while  percussing.  It  is  equally  difficult  in  children,  as  the  space 
over  which  the  dulness  is  perceived  is  very  small.  In  adults 
the  dulness  ordinarily  spreads  over  two,  or  nearly  two,  intercostal 
spaces.  Its  transverse  diameter  in  a  grown  person  of  medium 
size  is  about  two  inches  and  a  half.  In  tall,  broad-chested  men 
it  is  upwards  of  three  inches.  Such,  at  all  events,  is  the  result  of 
measurements  I  have  made.  It  does  not  agree  with  the  statement 
of  Hughes  Bennett,  that  if,  as  a  general  rule,  the  transverse  diam- 
eter of  the  dulness  measure  more  than  two  inches,  the  heart  is 
abnormally  enlarged. 

The  range  of  the  dulness  is  changed  by  a  number  of  causes, 
physiological  as  well  as  pathological.  A  full  inspiration  alters  it 
materially,  by  bringing  the  lung  down  over  the  heart,  and  by 
displacing  the  organ  itself      The  upper  border  of  the  percus- 


DISEASES   OF   TPIE    HEART.  .38.3 

sion  dulness  shifts  to  the  extent  of  an  intercostal  space.  Below 
the  nipple,  between  the  fifth  and  sixth  ribs,  the  sound  becomes 
clear ;  but  over  the  dislodged  lower  part  of  the  heart,  the  beat 
of  which  is  distinctly  seen  under  the  cartilages  of  the  ribs,  at  a 
point  varying  from  three-fourths  to  one  and  a  fourth  inch  from 
the  median  line,  there  is  dulness  with  resistance  to  the  finger.  A 
full  expiration  produces,  for  the  most  part,  converse  phenomena. 
It  enlarges  the  boundaries,  especially  in  an  upward  and  transverse 
direction.  The  dulness  reaches  nearly,  or  even  entirely,  across 
the  sternum.  Auscultatory  percussion  enables  us  to  fix  the  per- 
cussion limits  more  closely. 

The  area  of  dulness  is  diminished  in  emphysema.  It  is  in- 
creased by  a  shrinking  of  the  left  lung,  and  by  diseases  of  the 
heart  and  of  its  membranes.  Prominent  among  these  stand 
hypertrophy,  dilatation,  and  an  eifusion  into  the  pericardial  sac. 

AUSCULTATION. 

When  the  ear  or  a  stethoscope  is  applied  over  a  healthy  heart, 
it  detects  two  sounds  of  very  dissimilar  character :  the  first  is 
long,  dull,  heavy,  and  corresponds  to  the  impulse  against  the 
walls  of  the  chest ;  the  second  is  short  and  flapping,  and  occurs 
after  the  impulse.  These  sounds  are  audible  at  all  parts  of  the 
prsecordial  region,  but  not  everywhere  with  equal  distinctness. 
The  first,  being  more  ventricular  in  origin,  is  best  heard  over  the 
lower  part  of  the  heart ;  the  second,  a  more  strictly  valvular 
sound,  is  more  defined  at  the  base. 

It  has  been  already  stated  that  these  sounds  are,  to  a  great  ex- 
tent, produced  by  the  play  of  the  valves.  Each  of  these  forms  a 
separate  sound,  or  at  least  a  portion  of  one.  Now,  experience 
teaches  that  there  are  points  at  which  the  sounds  of  the  several 
parts  of  the  heart  may  be  isolated.  Some  of  these  points  accord 
with  the  anatomical  seat  of  the  valves ;  others  do  not.  None  do 
so  very  closely ;  and  the  proximity  of  the  valves  to  one  another  is 
such  as  to  make  it  desirable  that  the  localities  selected  for  listening 
to  them  should  be  some  distance  apart. 

Clinical  observation  sanctions  the  following  :  the  sounds  of  the 
aorta  are  to  be  studied  at  the  right  edge  of  the  sternum,  in  the 
second  intercostal  space ;  from  there  the  stethoscope  may  be  car- 
ried to  the  second  costal  cartilage  of  the  right  side,  the  "aortic 


384 


MEDICAL   DIAGNOSIS. 


cartilage/'  and  clown  to  the  left  edge  of  the  sternum  opposite  the 
third  intercostal  space ;  that  is,  not  far  from  the  seat  of  the  aortic 
valves.  The  pulmonary  orifice  lies  very  close  to  them ;  but  the 
artery  itself  ascends  to  the  second  costal  cartilage  on  the  left  side. 


Fig 


^or^ic  'VO'Zves 


*tirlTnoTva7y  nrter^  voIajcs 


iJTilraL 


Diagram  showing  the  points  at  which  the  separate  valves  may  be  listeneil  to. 

Its  sound  may,  therefore,  be  isolated  in  the  second  intercostal 
space,  near  to  the  left  edge  of  the  sternum.  The  mitral  is  listened 
to  immediately  above  the  beat  of  the  apex.  The  sounds  of  the 
tricuspid  and  of  the  right  ventricle  may  be  sought  for  in  the 
vicinity  of  and  somewhat  above  the  ensiform  cartilage. 

Both  sounds  are  discerned  at  each  of  these  points.     But  the 


DISEASES    OF    THE    IIEAr.T.  385 

same  sound  varies  in  different  situations.  The  first  sound  over 
the  left  ventricle  near  the  a])ex  of  the  heart  is  dull,  heavy,  and 
prolonged ;  that  over  the  right  ventricle  is  clearer,  shorter,  and  of 
higher  pitch.  The  second  sound  heard  there  jjresents  no  constant 
and  appreciable  variance  from  that  over  the  left  ventricle  ;  yet  it  is 
less  ringing  and  distinct  than  the  second  sound  of  the  pulmonary 
artery  and  aorta.  Even  these  two  are  not  precisely  alike.  The 
second  sound  of  the  latter,  when  compared  with  that  of  the 
former,  is  found  to  be  sharper  and  more  accentuated.  The  first 
sound,  however,  does  not  diifer  materially  from  that  of  the  pul- 
monary artery.  But  the  first  sound  of  both  does  differ  most 
materially  from  that  over  the  ventricles.  Compared  with  the  first 
sound  over  the  right  ventricle,  the  first  sound  of  the  pulmonary 
artery  is  much  duller,  more  indistinct  and  like  a  vibration,  and 
not  of  so  high  a  pitch.  Compared  with  the  first  sound  at  the 
apex,  the  first  sound  of  the  aorta  lacks  the  weighty,  prolonged 
character  which  belongs  to  the  ventricular  sound. 

These  statements  are  based  on  a  series  of  observations  made, 
some  with  an  ordinary  stethoscope,  some  with  a  double  stetho- 
scope. They  certainly  seem  to  favor  the  view  of  Skoda,  that 
the  first  sound,  as  heard  over  the  great  vessels,  is  not  merely  a 
transmitted  sound,  but  is  one  which  is  partly,  if  not  entirely, 
generated  by  the  arteries  themselves  when  the  blood  rushes  into 
them. 

The  sounds  just  considered  undergo  various  modifications,  both 
when  the  heart  is  affected  and  when  it  is  free  from  disease.  They 
may  be  audible  over  a  larger  space  of  the  chest  than  usual ;  they 
may  be  changed  in  character  and  in  rhythm.  Their  transmission 
over  a  larger  space  is  an  unimportant  sign.  They  are  undoubtedly 
perceived  over  a  more  extended  surface  when  the  heart  is  enlarged  ; 
but  they  are  equally  or  more  diffused  when  the  surrounding  tissues 
are  condensed.  And  even  in  perfect  health  their  range  is  very 
diversified. 

During  a  full  inspiration,  the  sounds  at  the  interspace  between 
the  second  and  third  costal  cartilages  on  the  left  side  disappear 
almost  entirelv,  and  become  faint  at  the  aortic  cartilage.  The 
first  sound  at  the  apex  lessens  also  very  much  in  distinctness,  but 
it  is  better  heard  at  a  new  point  of  impulse,  visible  toward  the 
median  line  end  just  below  the  cartilages  of  the  ribs.     During  a 

25 


386  MEDICAL    DIAGNOSIS. 

full  expiration,  the  extent  ovev  which  the  heart-sounds  are  per- 
ceived is"  i  nereased. 

The  sounds  grow  in  loudness  in  any  functional  disturbance  of 
the  lieart.  AVhon  the  oroan  is  palpitatinii;  vioknitly  under  strong 
nervous  excitcuicnt,  they  may  become  short  and  sharp,  and  some- 
times so  loud  and  ringing  as  to  be  audible  to  the  by-standers. 
They  are  often  permanently  louder  than  in  health,  and  are  shorter 
and  more  clearly  dehned  when  the  walls  of  the  heart  are  thinned. 
This  is  particularly  the  case  with  the^rs^  sound.  When  the  walls 
of  the  heart  are  thick,  the  first  sound  over  the  hypertrophied  por- 
tion is  apt  to  be  dull  and  prolonged.  The  first  sound  is  weakened 
if  the  structure  of  the  heart  be  softened  :  hence  it  is  feeble  in  some 
low  fevers,  and  in  fatty  degeneration  of  the  organ.  It  is  also  less 
distinct  when  there  is  a  want  of  tone  in  the  muscle,  or  when  the 
mitral  and  tricuspid  valves  are  thickened. 

To  determine  whether  a  dull  first  sound  at  the  apex  be  due  to 
an  injured  mitral  valve,  or  to  an  alteration  of  the  muscular  power 
of  the  lieart,  Flint  advises  to  place  the  stethoscope  over  the  apex 
of  the  heart,  and  then  on  the  outside  of  the  left  nipple  to  isolate 
the  element  of  im])ulsion,  which  unites  with  the  valvular  element 
to  form  the  complex  first  sound.  If  there  be  a  marked  impulsion 
over  the  apex,  but  if  by  means  of  the  stethoscope  placed  to  the 
left  we  perceive  no  sound  at  all  which  possesses  a  valvular  char- 
acter, or  hear  a  sound  which  is  but  faintly  valv^ular,  we  infer  that 
the  mitral  valves  are  more  or  less  damaged. 

The  second  sound  is  not  so  liable  to  be  changed  as  the  first.  It 
is  rendered  somewhat  duller  by  a  thickening  of  the  semilunar 
valves;  on  the  other  hand,  it  is  more  ringing  when  they  are  tliin, 
and  in  great  functional  excitement  of  the  heart,  and  in  altered 
blood  conditions,  as  in  lithfemia  or  in  gout.  The  sound,  indeed, 
always  becomes  more  distinctly  accentuated  if  the  column  of 
blood  close  tlie  valves  forcibly.  This  occurs  not  unfrequently 
in  hypertrophy  of  the  ventricles.  It  also  takes  place  where  a 
decided  obstruction  exists  to  the  passage  of  blood  through  the 
lungs.  It  is  then  over  the  pulmonary  artery  alone  that  this 
accentuated  second  sound  is  audible. 

Both  the  sounds  are  occasionally  obscure  and  seem  to  arrive 
at  the  ear  from  a  distance.  This  happens  when  fluid  has  ac- 
cumulated in  the  pericardium.     The  sounds  may  be  changed  in 


DISEASES   OF   THE   HEART.  387 

their  relative  proportion  to  cacli  other,  and  the  pauses  between 
them  be  lengthened  or  shortened,  or  else  the  sounds  may  intermit 
from  time  to  time.  From  this  perverted  rhythm  we  do  not 
derive  any  definite  instruction  as  to  the  condition  causing  it. 
It  serves  only  to  show  that  the  heart  is  acting  irregulai'ly,  and 
thus  directs  our  attention  to  the  state  of  the  organ.  It  may  be 
associated  with  organic  disease  or  exist  without  it.  The  same 
may  be  said  of  reduplication  of  the  sounds  of  the  heart.  The 
second  sound  is  the  one  which  is  generally  split.  Yet  both  of 
them  may  be  doubled,  or  one  may  be  doubled  over  one  part  of 
the  heart  and  not  over  another ;  so  that  four  or  three  sounds  are 
counted  to  each  beat  of  the  pulse.  The  cause  of  the  reduplication 
is  the  want  of  synchronous  action  of  the  two  sides  of  the  heart. 
The  direct  value  for  diagnosis  of  the  altered  movement  is  not 
great ;  but  indirectly  it  teaches  a  most  important  lesson :  it  tells 
us  that  each  side  of  the  heart  forms  its  own  sounds,  and  that, 
to  arrive  at  accurate  conclusions,  each  side  has  to  be  separately 
examined.  Yet  there  is  some  diagnostic  value  to  be  attached  to 
the  changed  rhythm.  Thus,  the  peculiar  alteration  of  the  sounds, 
which  causes  us  to  hear  three  sounds  during  the  action  of  the 
heart,  audible  over  the  whole  organ,  tw^o  of  them  in  the  diastole, 
producing  the  rhythm  that  has  been  likened  to  the  gallop  of  a 
horse,  is  often  found  in  contracted  kidney.  Fraentzel*  has  noted 
its  frequent  occurrence  in  typhoid  fever  and  in  croupous  pneu- 
monia, and  looks  upon  it  as  a  sign  of  grave  cardiac  weakness. 

Such,  then,  are  the  modifications  which  the  healthy  sounds 
present.  At  times  we  meet  with  sounds  which  do  not  in  the 
least  resemble  those  naturally  heard,  and  which  overshadow  them 
or  take  their  place.  They  are  called  murmurs,  and  are  mainly 
produced  either  within  the  heart  or  on  its  surface. 

Those  murmurs  which  are  endocardial  have  a  common  quality : 
they  are  more  or  less  blowing.  Yet  the  sound  is  not  always  of 
the  same  character  or  pitch.  It  may  be  low-toned,  it  may  be  high- 
pitched  ;  it  may  be  soft,  it  may  be  harsh ;  it  may  resemble  the 
blowing  of  a  bellows,  it  may  be  musical ;  or  it  may  be  filing,  or 
rasping,  or  sawing.     The  ingenuity  of  every  listener  exerts  itself 


*  Krankheiten  des  Herzens,  Berlin,  1889 ;   see  also  CufFer  and  Barbilliou, 
Arch.  Gen.  de  Med.,  1887. 


388  MEDICAL    DIAGNOSIS. 

in  tracing  a  similarity  to  some  familiar  noise ;  but  all  to  no  prac- 
tical purpose.  These  different  sounds  have  not  been  proved  to 
have  a  significance  beyond  that  of  a  blowing  sound.  They  teach 
us  nothing  certain  as  to  its  source.  They  are,  moreover,  not  at 
all  times  the  same  in  the  same  case,  since  the  heart  when  excited 
may  emit  a  sound  different  from  that  which  it  does  when  it  is 
beating  quietly. 

A  blowiuii-  sound  orio-inates  in  the  altered  relation  of  the  blood 
to  the  part  over  Avhich  it  moves.  This  general  statement  opens 
the  way  to  the  consideration  of  the  specially  acting  elements,  both 
in  the  blood  and  in  the  heart  itself. 

]\Iost  usually  a  cardiac  murmur  springs  from  a  change  at  one 
of  the  orifices.  This  may  be  either  a  narrowing  or  a  roughening, 
which  interposes  a  local  obstruction  to  the  flow  of  the  blood,  or  it 
may  be  an  insufficiency  to  close  the  opening.  In  the  latter  case 
the  blood  regurgitates,  and  a  murmur  is  occasioned  by  tlie  de- 
viation of  the  direction  of  the  current  and  the  establishment  of 
another.  This  subversion  of  the  course  of  the  circulating  fluid, 
added  to  its  increased  velocity  and  force,  is  one  of  the  chief  sources 
of  those  temporary  blowing  sounds  not  unfrequently  jDcrceived 
when  a  heart  is  violently  excited,  while  both  its  valvular  ap- 
paratus and  its  muscular  texture  are  healthy.  But  we  meet 
every  now  and  then  with  instances  where  none  of  these  causes 
are  present,  and  wliere  altered  blood  is  the  foundation  of  the 
murmur. 

Thus,  to  sum  up  the  subject,  we  find  murmurs  which  depend 
upon  organic  change,  and  murmurs  which  are  unconnected  with 
any  structural  alteration ;  and  these  inorganic  murmurs  are  due 
either  to  an  unnatural  condition  of  the  blood  or  to  temporarily 
perverted  action  of  the  heart. 

The  murmurs,  however  caused,  have  different  effects  on  the 
sounds  of  the  heart.  They  either  accompany  the  sound  through- 
out the  whole  or  a  part  of  its  duration,  and  tluis  obscure  it,  Or 
else  they  take  its  place  and  hinder  it  from  being  generated.  In 
time  of  their  occurrence  they  correspond  to  the  contraction  or  to 
the  dilatation  of  the  heart,  and  therefore  to  the  first  or  to  the 
second  sound ;  at  least,  they  do  so  ])ractically.  It  is  true,  they 
may  immediately  precede  or  succeed  either  sound,  or  fill  mainly  the 
intervals  of  silence  between  them ;  but  attention  to  such  minute 


DISEASES    OF    THE    HEART.  389 

divisions  is  irksome,  and,  for  ordinary  purposes,  unnecessary. 
In  point  of  fact,  it  is  often  difficult  enough  to  say  whether  the 
murmur  we  hear  is  systolic  or  diastolic.  The  readiest  method  of 
judging  of  the  time  of  the  production  of  a  murmur  is  to  feel 
with  the  finger  for  the  impulse  while  listening  with  the  stetho- 
scope. The  blowing  sound  which  agrees  with  the  beat  of  the 
heart  is  systolic ;  the  one  between  the  beats  is  diastolic. 

When  a  murmur  is  once  established,  it  attends  each  motion  of 
the  heart  that  can  give  rise  to  it ;  but  it  is  not  always  equally 
perceptible.  It  may  become  very  faint,  or  disappear  entirely,  by 
the  patient  changing  his  position.  It  is  sometimes  manifest  only 
when  the  heart  is  acting  strongly.  Indeed,  it  always  requires  a 
certain  force  and  velocity  in  the  passage  of  the  blood  to  generate 
a  murmur.  Yet  overaction  of  the  heart  may  be  as  destructive  of 
its  distinctness  as  diminished  action.  This  is,  however,  a  matter 
that,  should  it  be  desirable  for  diagnosis,  Ave  can  control  by  the 
administration  of  medicines  like  digitalis,  aconite,  or  veratrum 
viride,  provided  their  use  be  not  contra-indicated. 

A  murmur  is  sometimes  heard  by  the  patient  himself,  or  is 
audible  before  the  ear  is  placed  over  the  heart.  It  may  be  per- 
ceived as  an  abrupt  blowing  sound,  apparently  coming  out  of  the 
mouth.  A  gentleman,  whose  mitral  valves  permitted  of  regur- 
gitation, was  under  my  charge.  When  he  held  his  breath  and 
kept  his  mouth  open,  he,  as  well  as  I,  could  detect  an  abrupt 
blowing  sound  issuing  from  the  oral  cavity.  This  sound,  when 
the  heart's  action  was  at  all  excited,  accompanied  regularly  each 
impulse. 

Posture  exerts  a  decided  effect  upon  murmurs.  A  blowing 
sound  distinct  in  the  recumbent  position  may  become  very  faint 
or  disappear  when  the  patient  stands  erect ;  and  the  reverse  holds 
good,  although  less  common.  The  nature  of  the  murmur — 
whether  organic  or  inorganic  —  does  not  seem  to  influence  the 
readiness  with  wdiich  it  is  affected  by  change  of  posture,  though 
anemic  murmurs  are  thought  to  be  more  intense  in  the  recumbent 
posture.*  Pressure,  too,  has  an  influence  upon  the  abnormal  car- 
diac sound ;  it  notably  augments  it,  and  often  raises  its  pitch. 
Yet  pressing  the  stethoscope  firmly  against  the  chest  does  not 

*  James  H.  Hutchinson,  Amer.  Journ.  Med.  Sci.,  April,  1872. 


390  MEDICAL    DIAGNOSIS. 

occasion  as  much  alteration  in  endocardial  as  it  does  in  pericardial 
sounds. 

A  innrnHH-  nia}-  be  obscured  by  the  respiratory  sound;  but  this 
is  not  apt  to  be  a  cause  of  error  in  diagnosis.  It  is  not  nearly  so 
fruitful  a  source  of  mistake  as  considering  the  natural  sounds 
of  the  lungs  to  be  blowing  sounds  in  the  heart.  Certainly  the 
resemblance  is  often  great ;  but  blunders  may  be  readily  avoided 
by  listening  to  the  heart  while  the  patient  suspends  his  breathing. 

Having  ascertained  positively  the  existence  and  the  time  of 
occurrence  of  an  endocardial  murmur,  the  next  tiling  is  to  deter- 
mine its  exact  seat,  and,  if  possible,  its  immediate  cause.  The  scat 
of  the  murmur  is  judged  of  by  the  place  of  its  greatest  intensity, 
and  by  the  relation  this  bears  to  one  of  the  four  points  for  the 
clinical  examination  of  the  heart  above  described.  If  it  be  most 
distinct  at  or  near  the  apex  of  the  heart,  it  is  produced  at  the 
mitral  orifice ;  if  immediately  above  or  at  the  ensiform  cartilage, 
it  is  generated  in  the  right  ventricle  and  at  the  tricuspid  opening. 
If  we  hear  it  most  plainly  at  the  sternum,  somewhat  toward  its 
left  border  on  a  level  with  the  third  intercostal  space  or  even 
the  fourth  rib,  and  with  equal  or  nearly  equal  distinctness  at  the 
second  costal  cartilage  on  the  right  side,  we  are  enabled  to  decide 
that  it  is  developed  at  the  origin  of  the  aorta.  The  pulmonary 
artery  is  not  often  the  seat  of  a  murmur.  When  it  is,  this  is 
clearly  perceptible  in  the  second  intercostal  space  on  the  left  side, 
and  extends,  if  the  valves  be  diseased,  to  the  junction  of  the  third 
left  cartilage  with  the  sternum ;  although  we  must  bear  in  mind 
that  occasionally  in  mitral  affections  the  murmur  is  loudest  in  the 
pulmonary  area,  or,  as  ISTaunyn  has  shown,  not  exactly  over  the 
artery,  but  rather  an  inch  and  a  half  or  more  from  the  left  edge 
of  the  st<^rnimi  in  the  second  interspace. 

Any  of  these  situations  may  be  the  site  of  a  distinct  murmur 
occupying  only  one  sound  of  the  heart,  or  being  produced  in  both, 
— one  murmur  taking  place  with,  the  other  against,  the  current  of 
blood.  Yet  it  rarely  happens  that  the  murmur  is  strictly  limited 
to  one  of  these  positions  :  it  will  mostly  extend  in  various  direc- 
tions from  its  point  of  intensity,  grooving  fainter  and  fainter  as 
this  is  left.  A  blowing  murmur  thus  transmitted  may  drown  the 
natural  sounds  of  the  heart  at  the  parts  not  diseased.  But  when 
one  orifice  only  is  affected,  we  can  usually  hear  the  sounds  at  the 


DISEASES    OF   THE    HEAKT.  391 

other  valves.  They  may  be  obscured,  but  still  they  exist ;  and  it 
is  a  vast  aid  when  they  are  heard,  since  they  set  the  limits  to  the 
disease.  How  important  is  it,  then,  to  examine  each  portion  of 
the  heart  separately,  as  much  for  the  purpose  of  saying  what  is 
not  as  what  is  deranged  ! 

If  satisfied  as  to  the  seat  of  the  murmur,  we  naturally  turn  to 
inquire  into  its  origin.  Is  it  caused  by  an  alteration  of  the  valves  ? 
Is  it  unconnected  with  any  appreciable  change  of  structure  in  the 
heart  ?  There  is  nothing  in  the  murmur  itself  which  will  tell  us 
positively.  As  a  rule,  it  is  true  that  a  harsh  murmur  results  from 
organic  disease,  and  a  soft  murmur  is  inorganic ;  but  we  judge 
with  much  more  certainty  by  the  time  of  the  occurrence  of  the 
blowing  sound  and  by  the  accompanying  phenomena.  A  murmur 
attending  the  distention  of  the  ventricles  shows  that  the  orifices 
are  injured.  A  systolic  murmur  may  be  either  organic,  or  it  may 
indicate  simply  a  change  in  the  state  of  the  blood,  or  of  the  force 
and  velocity  with  which  it  is  circulating.  In  the  latter  case,  how- 
ever, the  abnormal  sound  is  temporary,  and  disappears  with  the 
excitement.  If  arising  from  an  impoverished  state  of  the  blood, 
it  is  generally  soft,  of  low  pitch,  is  perceived  over  the  base  of  the 
heart,  and  is  accompanied  by  a  humming  sound  in  the  veins  of 
the  neck.  It  may  be  heard  over  the  right  base,  or  on  the  left 
side  over  the  pulmonary  artery ;  although  Balfour  maintains  that 
it  is  not  really  over  the  pulmonary  artery,  but  about  half  an  inch 
or  more  to  the  left  of  the  pulmonary  area,  and  is  not  an  arterial, 
but  an  auricular  sound. 

Throughout  the  consideration  of  the  endocardial  murmurs,  they 
have  been  treated  as  originating  at  the  seat  of  the  valves.  In 
truth,  it  is  there  that  they  are  formed.  Still,  they  are  occasion- 
ally due  to  morbid  states  in  the  body  of  the  ventricle,  or  in  the 
auricle.  But  in  either  case,  then,  they  are  clinical  curiosities. 
As  regards  the  auricles,  they  yield  no  appreciable  sound  in  health, 
nor  are  they  in  disease  except  rarely  the  source  either  of  sound 
or  of  murmur. 

A  blowing  sound  is  not  of  necessity  limited  to  the  heart :  it 
may  be  transmitted  all  over  the  arterial  system.  Yet  it  would 
be  a  great  mistake  to  suppose  that  every  murmiu'  heard  over  the 
arteries  is  connected  with  a  disease  of  the  heart.  It  is  often  but 
the  sign  of  impoverished  blood,  or  a  sound  dependent  upon  local 


392  MEDICAL   DIAGNOSIS. 

roughening  or  narrowing  of  the  tube.  The  latter  may  be  tem- 
porarily produeccl  by  the  pressure  of  a  stethoscope, — a  fact  of 
which  it  is  well  to  be  aware.  It  is  even  stated  that  pressure  over 
a  healthy  heart  may  generate  a  murmur ;  but  I  have  never  been 
able  to  siitisfy  myself  of  the  truth  of  tliis  statement.  It  is  cer- 
tainly incorrect  as  a  general  nde,  and  the  murnnir  deixnids,  when 
it  happens,  more  likely  upon  the  condition  of  the  blood  and  tlie 
force  with  wliich  it  circulates. 

Let  us  now  examine  the  sounds  which  originate  on  the  outside 
of  the  heart.  These  peiicardial  tiiurmurt^  have  all  a  common 
source  :  they  all  result  from  irregularities  on  tlie  membrane. 
Like  the  pleura,  the  smooth  serous  covering  of  the  heart  moves 
noiselessly  in  health  ;  but  when  it  is  roughened  by  a  deposit  of 
any  kind,  the  friction  of  its  surfaces  gives  rise  to  a  sound  which 
may  be  single,  but  which  is  usually  double.  The  character  of 
this  sound  is  variable.  It  may  be  a  to-and-fro  rubbing  murmur, 
or  it  may  be  grazing,  or  scratching,  or  creaking,  or  whistling,  or 
clicking  and  resembling  the  valvular  sounds.  It  has  but  one 
quality  which  is  constant,  and  that  is  its  superficiality.  By  this 
superficiality ;  by  the  strict  limitation  of  the  sound  to  the  region 
of  the  heart ;  by  its  altering  from  time  to  time  its  precise  seat ; 
by  its  greater  extent  and  intensity  when  the  patient  bends  for- 
ward ;  by  its  occasional  increase,  and  even  change  of  character,  on 
external  pressure  ;  by  its  following,  rather  than  occurring  with, 
the  movements  of  the  heart;  and  by  the  sensation  of  friction 
which  it  communicates  to  the  finger, — we  know  that  the  sound 
heard  is  produced  on  the  surface  of  the  heart.  Yet,  in  spite  of 
this  array  of  points  of  diiference,  it  is  often  difficult  to  distinguish 
a  pericardial  from  an  endocardial  murmur. 

An  error  not  easy  at  times  to  avoid  is  the  failure  to  discriminate 
between  the  presystolic  apex  murmur,  regarded  as  characteristic 
of  mitral  constriction,  and  a  pericardial  friction  localized  near 
the  apex.  Tlie  only  trustworthy  points  of  distinction  are  that 
the  pericardial  sound  changes  in  its  quality  and  loudness,  that  it 
is  rendered  stronger  and  changed  in  pitch  by  pressure  exerted 
witli  the  stethoscope,  and  that  the  second  sound  at  the  left  base  is 
unaltered. 

A  friction  sound  is  prone  to  mask  the  natural  sounds  of  the 
heart.     At  times,  although  heard  over  the  cardiac  region,  it  is  not 


DISEASES   OF   THE   HEART.  393 

due  to  inflammation  of  the  pericardium.  The  exudation  may  bo 
on  the  surface  of  the  pleura  adjacent  to  the  pericardium,  and  the 
murmurs  be  caused  solely  by  the  movements  of  the  heart,  with 
the  rhythm  of  which  they  coincide.  Sometimes,  again,  the 
sound  heard  in  the  cardiac  region  is  in  reality  the  rubbing  of 
an  inflamed  pleura.  If  any  doubt  exist,  let  the  patient  be  told 
to  suspend  his  breathing.  As  this  is  stopped,  the  pleural  sound 
ceases. 

Such  is  a  brief  description  of  the  different  physical  signs  met 
with  in  examining  the  heart,  both  in  health  and  in  disease. 
Their  importance  for  diagnosis  it  is  difiicult  to  overestimate.  A 
knoAvledge  of  the  physical  signs  is  the  solid  foundation,  without 
which  any  structure  that  may  be  raised  will  soon  tumble  to  pieces. 

The  General  and  Local  Symptoms  of  Diseases  of  the  Heart. 

It  is  not  easy  to  say  what  are  and  what  are  not  the  symptoms 
that  belong  to  diseases  of  the  heart.  There  are  vital  manifestations 
directing  attention  to  the  heart  which  are  not  associated  with  any 
change  in  its  structure;  and  most  serious  changes  in  its  structure 
may  occur  without  any  of  these  vital  manifestations.  Yet  we  often 
find  a  significant  group  of  symptoms  which  accompany  an  aflFection 
of  the  heart.  Some  of  these  attest  directly  the  organ  disturbed, 
such  as  pain  in  the  cardiac  region,  and  palpitation.  Others  are  the 
indirect  and  more  remote  expressions  of  its  derangement,  such  as 
cough,  dyspnoea,  hemorrhages,  dropsy,  disorders  of  the  brain  and 
nervous  system,  engorgement  of  the  abdominal  viscera,  a  peculiar 
state  of  the  arteries  and  veins,  and  the  aspect  of  the  face.  It  is 
unnecessary  to  do  more  than  mention  some  of  these,  since  several 
have  been  already  described  in  connection  with  pulmonary  com- 
plaints, and  there  is  nothing  in  the  cough  or  in  the  shortness  of 
breath  by  which  we  can  absolutely  determine  it  to  be  caused  by  a 
disease  of  the  heart.  The  same  with  respect  to  the  hemorrhage  : 
there  is  nothing  characteristic  about  it.  It  simply  proves  the  efiForts 
of  the  blood-vessels  to  relieve  themselves  of  the  strain  Avhich  the 
disturbance  in  the  flow  of  ihe  blood  has  put  on  them.  The  capil- 
laries and  the  smaller  blood-vessels  give  way  first ;  partly  from 
the  reason  just  assigned,  and  partly  from  the  altered  state  of  their 
coats,  a  common  associate  of  cardiac  disease.     These  hemorrhages 


394  MEDICAL    DIAGNOSIS. 

arc  prone  to  happen  fVoni  the  bronchial  tubes  and  the  hnios,  and 
the  blood  is  cx])eetorated ;  but  thev  may  also  take  place  directly 
into  the  ]nihn()narv  tissue,  or  into  or  from  any  part  of"  the  body. 
Their  danger  is  in  proj)ortion  to  the  amount,  to  the  importance  of 
the  function  of  the  structures  into  "vvhich  the  blood  is  effused,  and 
to  the  possibility  of  its  finding  an  outlet.  The  peril  is  greatest 
when  the  blood  is  poui'cd  out  into  the  brain. 

Cardiac  Dropsy. — The  dro})sy  caused  by  a  disease  of  the 
heart  is  met  with  in  different  situations:  in  the  cellular  tissues, 
in  the  peritoneal  and  pleural  cavities,  in  the  pericardium,  in  the 
ventricles  of  the  brain  and  under  the  arachnoid,  in  the  air-cells 
of  the  lungs, — in  fact,  in  any  part  where  fluid  can  exude,  and 
where  there  is  a  space  which  can  receive. 

In  anasarca  dependent  upon  a  cardiac  lesion,  the  dropsical 
swelling  begins  about  the  ankles  and  feet:  hence  oodema  starting 
in  this  situation  is  regarded  as  among  the  surest  of  the  symptoms 
of  a  disease  of  the  heart.  The  accumulation  is  much  influenced 
by  position :  the  feet  are  more  puffy  to\vard  evening,  when  the 
patient  has  been  all  day  in  the  erect  posture,  and  least  so  when 
he  gets  up  in  the  morning. 

AVhat  the  condition  of  the  heart  is  that  gives  rise  to  dropsy, 
has  been  made  a  matter  of  much  dispute.  It  has  been  held  to  be 
uniformly  connected  with  dilatation  of  the  right  side  of  the  heart. 
It  has  been  taught  to  be  invariably  linked  to  a  valvular  affection. 
Clinical  experience  shows  us  that  it  may  or  may  not  exist  where 
these  states  are  present.  The  dropsy  is  most  constantly  found  to 
be  associated  with  an  imjuxlimcnt  to,  or  disturbance  in,  the  flow 
of  the  venous  blood,  and  therefore  Avith  disorder  of  the  right  side 
of  the  heart,  particularly  with  a  dilatation  of  the  cavities.  It  may 
be  permanent  or  not.  Its  extent  certainly  docs  not  bear  a  con- 
stant relation  to  the  extent  of  the  cardiac  disease.  It  bears  a 
more  constant  relation  to  the  amount  of  venous  congestion,  and 
to  the  impoverishment  of  the  blood. 

Derangement  of  the  Circulation. — Unmistakable  evi- 
dence of  tlic  obstruction  to  the  flow  of  the  blood  through  the 
veins  is  afforded  by  their  prominence  in  different  portions  of  the 
body.  This  is  especially  manifest  in  the  superficial  veins  of  the 
neck,  which,  moreover,  when  the  tricuspid  orifice  is  permanently 
open,  exhibit  a  distinct  pulsation  Avith  each  beat  of  the  heart. 


DISEASES   OF   THE   HEART.  395 

The  turgid  condition  of  the  venous  system  is  rendered  equally 
obvious  by  the  livid  tinge  of  the  skin  and  the  bluish  color  of  the 
lip,  and  by  ramifications  of  fine  bluish  vessels  on  the  surface. 
But  the  arterial  system  may  also  be  gorged,  and  we  may  find  the 
capillaries  and  the  smaller  arteries  seemingly  ready  to  burst.  The 
conjunctiva  is  then  highly  injected,  and  the  cheek  has  a  coarse, 
red  look.  This  change  in  the  color  and  appearance  of  the  face, 
the  thickening  of  the  eyelids,  and  the  prominent  eye,  make  up 
the  peculiar  physiognomy  of  a  chronic  cardiac  malady.  The 
state  of  the  larger  arteries  is  very  variable,  and  mainly  according 
to  the  nature  of  the  disorder.  The  pulse  may  be  small  and  tense  ; 
it  may  be  full ;  it  may  be  rebounding ;  it  may  be  very  irregular ; 
and  it  is  often  out  of  all  proportion  to  the  forcible  action  of  the 
heart. 

The  derangement  of  the  circulation  of  individual  parts  maui- 
fests  itself  by  special  symptoms.  It  shows  itself  in  the  brain  by 
attacks  of  cerebral .  congestion  ;  by  vertigo  ;  by  violent  headache, 
occurring  in  spells,  or,  less  acute,  in  dull  persistent  ache,  increased 
on  exertion, — a  form  especially  met  with  in  children.  We  see 
evidences  of  the  congestion  of  the  nervous  system  in  the  disturbed 
dreams ;  in  the  sudden  starting  up  from  sleep ;  in  the  irregular 
action  of  certain  muscles ;  in  the  spots  which  float  before  the  eye. 
It  is  possible  that  the  strange  sense  of  insecurity,  and  the  irrita- 
bility, of  which  patients  afflicted  with  a  cardiac  malady  complain, 
are  produced  by  the  same  cause.  At  any  rate,  whether  produced 
thus  or  not,  they  aj-e  remarkable  symptoms.  There  is  no  disease 
which  unnerves  more  than  a  disease  of  the  heart.  Indeed,  the 
mere  fear  of  its  presence  gives  rise  to  restlessness  and  gloom,  and 
breeds  timidity  in  those  who  would  look  any  external  danger 
boldly  in  the  face. 

The  disordered  flow  of  blood  through  the  abdominal  viscera 
occasions  orranic  changes  and  a  disturbance  of  the  functions  of 
the  several  organs.  Thus,  the  liver  increases  in  size,  or  undergoes 
other  alterations  which  interfere  more  or  less  seriously  with  the 
elimination  of  the  bile ;  or  the  kidneys  no  longer  secrete  as  in 
health,  but  become  much  engorged  and  drain  off  the  albumen  of 
the  blood  ;  or  the  spleen  sustains  textural  transformations.  These 
states  all  tend  to  give  rise  to  more  and  more  dropsy,  and  hence  to 
more  and  more  suffering. 


396  MEDICAL   DIAGNOSIS. 

The  symptoms  which  point  most  directly  to  the  heart  itself  are 
palpitation  and  irrcgnlarity  of  action,  and  pain.  These  symptoms 
imply  that  the  fnnction  of  the  organ  is  disturbed,  or  that  its  in- 
nervation is  in  some  manner  deranged  ;  but  they  imply  nothing 
more.  They  are,  therefore,  common  to  functional  derangement 
which  occurs  associated  with  structural  changes  in  the  heart,  and 
to  purely  functional  derangement. 

Cardiac  Pain. — Pain  in  or  over  the  heart  is  met  with  both  in 
acute  and  in  chronic  diseases ;  yet  it  is  not  a  regular  or  well-defined 
symptom  of  either.  When  we  reflect  that  the  heart  may  be  pinched, 
may  be  torn,  without  exciting  any  suffering,  it  will  be  readily  un- 
derstood why  its  disorders  do  not  occasion  much  pain.  Indeed, 
many  a  case  of  enormous  enlargement  of  the  heart,  or  of  profound 
textural  alteration  of  its  walls  or  valvular  apparatus,  is  unaccom- 
panied by  pain.  Still,  we  meet  with  instances  in  which  distress  at 
the  heart  and  various  uneasy  sensations  are  among  the  more  marked 
symptoms  of  a  chronic  cardiac  lesion  ;  and  Ave  even  find  persons 
complaining  of  a  persistent  pain  in  the  heart,  which  extends  to 
the  left  side  of  the  neck  and  arm,  in  whom  this  symptom  has 
preceded  the  signs  of  a  disease  of  the  heart  or  of  its  great  vessels. 

In  the  acute  cardiac  affections  pain  is  a  not  inconstant  symptom. 
Uneasy  sensations,  not  amounting  perhaps  to  absolute  pain,  are 
complained  of  in  endocarditis.  Actual  pain  is  among  the  vital 
manifestations  of  inflammation  of  the  substance  of  the  heart,  and 
of  the  pericardium.  In  the  latter  disorder  it  is  usually  increased 
by  pressure,  and  is  frequently  very  severe.  But  no  suffering  is 
so  harrowing  as  that  av hich  happens  in  the  obscure  malady  termed 
angina  pectoris. 

Anr/ina  Pectoris. — Although  the  nature  of  this  complaint  may 
be  hidden,  the  symptoms  are  obvious  enough.  We  do  not  know 
what  the  precise  cause  of  this  angina  is ;  but  we  do  know  that 
the  disease  occasions  paroxysms  of  intolerable  anguish.  These 
paroxysms  come  on  suddenly,  and  pass  off  as  suddenly.  Their 
main  feature  is  an  agonizing  pain  in  the  pr?ecordia,  as  if  the  heart 
were  being  firmly  grasped  by  an  invisible  hand,  or  as  if  it  were 
being  torn  to  pieces.  The  ])ain  is,  however,  not  limited  to  the 
cardiac  region ;  it  radiates  in  various  directions,  shooting  to  the 
back,  to  the  neck,  and  especially  down  the  left  arm.  But  this 
is  not  all :  worse  than  the  pain  are  the  intense  anxiety  and  the 


DISEASES   OF   THE   HEART.  397 

feeling  of  impending  dcatli.  The  heart  palpitates  during  the  fit; 
yet,  if  we  judge  by  the  character  of  the  pulse,  its  movements  are 
not  always  materially  disturbed.  The  beat  of  the  artery  at  the 
wrist  may  be  small,  may  be  weak,  may  be  irregular,  may  be  accel- 
erated ;  but  it  may  also  be  full,  strong,  regular,  yet  not  increased 
in  frequency ;  again,  there  may  be  a  decided  difference  between 
the  pulses,  the  left  being  almost  or  quite  imperceptible.*  The 
face  is  generally  pale.  Difficulty  in  breathing,  contrary  to  what 
might  be  expected,  is  not  a  prominent  symptom,  and  is,  in  fact, 
often  wanting,  while  sometimes  the  breathing  is  irregular  and 
of  the  "  Cheyne-Stokes"  variety.  Giddiness,  spasmodic  seizures, 
temporary  coma,  perverted  sensibility,  occasionally  attend  or  fol- 
low the  cardiac  attack,  and  so  does  pericarditis. f 

The  duration  of  the  fits  is  as  uncertain  as  are  the  causes  which 
excite  them.  They  may  cease  in  a  few  minutes ;  they  may  last 
upward  of  an  hour.  They  come  on  rapidly,  without  any  assign- 
able reason  ;  they  are  reproduced  by  bodily  ailment,  by  exer- 
tion, by  fatigue,  by  exposure  to  cold,  or  by  mental  irritation. 
However  provoked,  they  are  always  dangerous.  The  heart  may 
stop  beating  during  the  paroxysm.  "  My  life  is  in  the  hands  of 
any  rascal  who  chooses  to  annoy  and  tease  me,"  was  a  saying  of 
John  Hunter.  And  in  truth,  after  he  had  suifered  for  years  from 
these  seizures,  his  ungovernable  temper  brought  on  one  in  which 
he  expired.  It  happens  sometimes  that  the  second  attack  follows 
at  a  short  interval  the  one  by  which  the  disease  first  declares 
itself,  and  proves  fatal.  Latham  |  narrates  the  history  of  two  cases 
of  this  kind.  In  one,  life  ceased  in  a  fortnight  after  the  first 
seizure;  in  the  other,  in  ten  days.  Nay,  it  may  be  cut  short 
even  in  tlie  midst  of  the  first  manifestation  of  the  malady.  Such 
was  the  death  of  Arnold  of  Rugby.§  On  the  other  hand,  I  have 
had  a  patient  under  my  care  who  for  weeks  at  a  time  has  five  or 
six  attacks  daily,  kept  in  check,  but  not  wholly  averted,  by  nitrite 
of  amyl. 

The  innuediate  conditions  on  which  the  symptoms  of  the  attack 
depend  are  veiled  in  obscurity.     Whether  they  be  or  be  not  pro- 

*  Hamilton  Osgood,  Amer.  Journ.  Med.  Sci.,  Oct.  1875. 

t  Clin.  Soc.  Transact.,  vol.  xvii.  p.  82. 

+  Lectures  on  Diseases  of  the  Heart,  vol.  11. 

^  Stanlej^,  Life  and  Correspondence  of  Thomas  Arnold. 


398  MEDICAL   DIAGNOSIS. 

duced  by  temporary  increase  of  weakness  in  an  already-enfeebled 
organ  ;  whether  a  cardiac  spasm  occnr  or  do  not  occnr ;  whether 
the  i)aiii  and  the  sensation  of  approaching  death  be  or  be  not 
caused  by  an  acute  distention  of  the  heart  with  blood, — we  do 
not  know.  All  we  do  know  positively  is,  that  the  excessive  jiain 
abruptly  ap[)caring  and  disappearing  points  to  deranged  innerva- 
tion. Yet  we  can  go  a  step  further;  we  can  say  with  certainty 
that  angina  pectoris  is  not  often  an  uncomplicated  neuralgia. 
Modern  research  has  taught  us  that  these  outbreaks  of  a  cardiac 
neurosis  are  frequently  linked  to  some  structural  change.  This 
structural  change,  so  far  as  we  can  now  see,  is,  however,  not  at 
all  times  the  same.  The  list  of  disorders  of  the  heart  and  arte- 
ries which  angina  pectoris  may  accompany  is,  indeed,  very  long. 
There  is  hardly  an  affection  of  the  walls  or  cavities  of  the  heart, 
scarcely  a  morbid  condition  of  the  arteries  that  nourish  it  or 
spring  from  it,  with  which  the  distressing  malady  has  not  been 
observed  to  be  associated.  It  has  been  found  as  an  attendant  on 
ossification  of  the  coronary  artery ;  on  every  form  of  valvular 
disease ;  on  thinning  of  the  parietes  of  the  heart ;  on  their  fatty 
softening ;  on  fungoid  growths  springing  from  the  apex  of  the 
organ.*  It  has  been  thought  that  combined  with  all  of  these 
states  is  fatty  degeneration,  which  thus  would  be  at  the  root  of 
the  angina.  Such  would  seem  to  be  the  result  of  the  observa- 
tions of  Quain.f  Whether  this  view  be  correct  or  not,  it  is  un- 
doubted that  fatty  degeneration  is  more  frequently  conjoined  with 
angina  than  is  any  other  organic  disease.  Yet  fatty  degeneration 
occurs  often  without  angina,  and  we  are  thus  forced  to  admit  that, 
however  frequent  the  association,  some  unknown  element  is  still 
here,  as  in  all  other  eases,  the  determining  cause.  During  the 
attack,  as  Brunton  has  shown,  there  is  a  vaso-motor  spasm  of  the 
smaller  vessels,  with  a  rise  in  blood -pressure  and  increased  tension 
in  the  arteries.  Angina  pectoris  is  now  very  generally  ranked 
among  the  vaso-motor  neuroses.| 

*  B.  Travers,  Medico-Cliirurgical  Transactions,  vol.  xvii. 

f  Medico-ChirurEcical  Transactions,  vol.  xxxiii. 

J  Landois's  physiological  analysis  suggests  four  varieties :  one  aftecting  the 
automatic  excito-motor  ganglia  of  the  heart;  the  second,  the  vagus,  either 
directly  or  hy  reflex  causes ;  the  third,  the  excito-motor  sympathetic,  the 
probable  seat  of  lesion  being  in  the  cardiac  plexus ;  the  fourth  being  a  vaso- 


DISEASE>S    OF    THE    HEAET.  399 

Angina  pectoris  is  easy  of  recognition.  The  points  to  ascertain 
in  diao-nosis  are,  whether  it  is  linked  to  an  organic  cause,  and  to 
what  organic  cause,  or  whether  it  is  a  pure  neurosis,  either  primary 
or  reflected.  It  may  be  a  question  whether  those  severe  pains  in 
the  region  of  the  heart,  which  occur  in  feeble  anaemic  persons  after 
unaccustomed  exertion,  or  which  are  brought  on  by  the  excessive 
use  of  tobacco,*  or  which  happen  in  rheumatic  or  gouty  subjects, 
especially  while  suffering  from  indigestion,  are  real  angina,  or 
whether  they  may  be  separated  from  this  affection.  They  differ 
from  it,  irrespective  of  being  far  less  violent  and  less  radiating, 
by  tl;e  circumstances  leading  to  an  attack,  and  by  their  constant 
association  with  palpitation.  Intercostal  neuralgia  with  palpita- 
tion might  be  mistaken  for  angina ;  but  the  painful  spots  in  the 
course  of  the  affected  nerve,  and  the  comparatively  slight  suffer- 
ing, distinguish  it.  In  truth,  it  is  a  complaint  seated  only  in  the 
thoracic  walls,  and  referred  by  the  patient  to  the  heart.  Great 
irritability  of  the  heart,  attended  with  faintness,  with  sensations  of 
sinking,  with  flushing  alternating  with  pallor,  and  with  pain,  due 
most  likely  to  a  neurosis  of  the  cardiac  plexus,  is  discriminated 
from  true  angina  by  the  palpitations,  and  by  their  connection 
with  pain  which  never  rises  to  the  anguish  of  angina  pectoris. 
Often,  too,  this  apparent  or  false  angina  is  found  in  persons 
who  are  hysterical,  or  are  subject  to  neuralgia,  or  are  laboring 
under  a  disorder  of  one  of  the  abdominal  viscera,  and  is  then 
clearly  reflex.  It  must,  however,  be  admitted  that  the  distinction 
between  true  and  false  angina  is  one  of  degree  rather  than  of  kind  ; 
for  the  cardiac  plexus  is  precisely  the  point  particularly  involved 
in  angina,  and  it  is  now  generally  thought  that  the  disturbance 
of  the  heart  in  this  painful  malady  occurs  mainly  through  the 
influence  of  the  sympathetic  fibres  which  meet  in  the  plexus. 

Another  complaint  that  may  be  confounded  with  angina  is 
what  may  be  called  cardiac  epilepsy.  In  this  rare  affection  in- 
tense pain  in  the  region  of  the  heart  happens  in  paroxysms.  But 
unconsciousness,  however  temporary,  occurs  also,  and  the  pain 

motor  angina.  In  the  second  form,  if  the  vagus  be  paralj^zed  there  is  greatly- 
increased  rapiditjj-  of  the  pulse,  with  sometimes  attacks  of  bronchial  asthma. 
Kredel,  Deutsches  Arch,  f  Klin.  Med.,  1882,  Bd.  xxx. 

*  Beau,  Journal  de  Medecine  et  Chirurgie,  July,  1862;  Eulenberg,  "An- 
gina," in  Ziemssen's  Cyclopaedia. 


400  MEDICAL    DIAGNOSIS. 

is  apt  to  follow  rather  than  to  precede  the  uneonsoiousncss. 
Yet  it  may  outlast  it,  and  become  associated  with  twitching  of 
the  muscles  of  the  face  and  with  other  spasmodic  movements. 
These,  the  unconsciousness,  and  the  time  at  which  the  pain 
happens,  distinguish  the  malady  from  those  instances  of  angina 
in  which,  owing  to  the  severity  of  the  pain,  the  patient  passes 
into  a  protracted  taint. 

Palpitation. — This  arises  in  various  diseases  of  the  heart.  It 
hap})cn.s  at  the  beginning  of  acute  affections ;  it  is  an  unfailing 
accompaniment  of  some  chronic  lesions.  It  is  especially  dis- 
tressing when  the  cavities  are  dilated  and  the  walls  of  the  organ 
thinned.  But  it  bears  no  positive  relation  to  any  special  cardiac 
malndv,  and  is  therefore  not  diagnostic  of  any.  So,  too,  with 
irregular  rhythm  of  the  heart's  action,  with  Avhich  palpitation  is 
in  truth  often  combined.  It  tells  us  nothing  more  than  that  the 
regular  movements  of  the  heart  are  disarranged.  Frequently  this 
disarrangement  is  due  to  a  serious  change  in  the  valves  or  in  the 
muscular  structure.  But  palpitation,  with  or  without  irregular 
rhythm,  may  take  place  in  a  perfectly  sound  heart, — sound,  at 
least,  so  far  as  our  means  of  investigation  enable  us  to  determine. 

Often  the  pulsations  of  the  heart  become  stronger,  more  exten- 
sive, and  more  perceptible,  from  mere  nervous  excitement.  But 
it  is  not  necessary  to  detail  the  symptoms  of  a  purely  nervous  pal- 
pitation. Every  one  has  experienced  them.  Every  one  knows 
that  there  is  a  feeling  of  slight  constriction  about  the  chest,  with 
a  hurried  breathing,  and  a  strange  sensation  as  if  the  heart  were 
leaping  from  its  i)lace.  Every  one  is  also  aware  that  the  organ 
is  felt  thumping  against  the  walls  of  the  chest,  and  with  a  force 
which  shakes  them.  The  popular  notion,  that  the  heart  is  the 
seat  of  the  emotions,  is  based  on  these  striking  evidences  of  its 
disturbed  action,  and  poets  have  seized  upon  and  delineated  with 
accuracy  some  of  the  even  more  strictly  physical  phenomena  of 
the  extended  impulse  under  strong  nervous  excitement.* 


*  Thus.  Shakespeare,  in  the  "  Kape  of  Lucrece:" 

"  His  hand,  that  yet  remains  upon  her  hrcast 
(Tiucle  ram  to  batter  such  an  ivory  wall !), 
May  feel  her  heart,  poor  citizen,  distressed, 
Wounding  itself  to  death,  rise  up  and  foil, 
Beating  her  hulk,  that  his  hand  shakes  withal.' 


DISEASES   OF   THE   HEART.  401 

But,  apart  from  the  increase  of  the  beat  by  mere  temporary 
agitation,  a  heart  may  act  overfreqiiently  and  ovcrstrongly  and 
its  action  become  sensible  to  the  person,  in  other  words,  it  may 
palpitate,  from  some  more  unremitting  excitement  dependent 
upon  perverted  innervation.  This  is  tlie  main  cause,  as  we  shall 
presently  see,  of  the  altered  impulse  of  the  heart  in  the  so-called 
functional  disorders. 

The  extreme  frequency  of  the  action  of  the  heart  is  in  some 
instances  remarkable.  I  have  known  it  beat  over  two  hundred 
times  in  the  minute.  On  the  other  hand,  the  deranged  innerva- 
tion may  lead  to  very  retarded  movement,  and  the  heart  beat  less 
than  thirty  times  in  the  minute.  We  may  find  this  sloio  action 
both  in  functional  and  in  organic  maladies,  though  it  is  most 
likely  that  the  nerve-centres  are  in  both  affected  in  the  same  way.* 

FUNCTIONAL  DISORDERS   OF   THE   HEART. 

It  has  just  been  stated  that  the  direct  symptoms  of  a  cardiac 
disorder — pain,  palpitation,  irregular  action — are  met  with  when 
no  recognizable  structural  change  has  taken  place.  Under  such 
circumstances  the  aifection  of  the  heart  is  termed  functional,  and 
its  symptoms  are  those  already  mentioned,  variously  combined, 
sometimes  the  one  predominating,  sometimes  the  other.  These 
functional  disorders  are  very  much  more  frequent  than  the  organic. 
They  are,  for  the  most  jaart,  produced  by  direct  excitement  of  the 
heart,  or  by  its  being  sympathetically  disturbed  by  some  source 
of  irritation  existing  remote  from  it,  or  in  the  system  at  large. 
The  symptoms  may  be  said  to  constitute  the  disease. 

Functional  Disorders  characterized  by  Palpitation,  associated 
or  not  with  Change  of  Ehythm. 

We  have  already  briefly  mentioned  the  causes  of  augmented 
action  which  are  associated  with  organic  changes,  and  those 
which  occasion  temporary  disturbance  of  the  heart.  A  more 
lasting  form  of  palpitation  is  engendered  when  the  organ  is  kept 
constantly  excited  by  a  deranged  condition  of  some  ^-iscus  re- 

*  See  a  very  interesting  analysis  of  ninety-one  cases,  by  Prentiss,  Transact. 
Assoc.  Amer.  Phys.,  vol.  iv.,  1889. 

26 


402  MEDICAL   DIAGXOSrS. 

mote  from  it ;  by  the  use  of  stimulatino;  substances ;  or  by  some 
general  morbid  states.  Thus,  a  disordered  stomaeh  or  liver  leads 
to  a  reflex  disturbance  of  the  heart,  which  ceases  if  the  disorder 
of  the  stomach  or  liver  be  remedied.  In  gouty,  lithannic,  and 
rheumatic  persons  the  heart  Irequently  pulsates  M'itli  increased 
quickness,  and  sometimes  with  marked  irregularity.  Special 
articles  of  diet,  especially  tea  or  coifee,  produce  palpitation ;  so 
does  the  inordinate  use  of  tobacco.  Masturbation  and  excessive 
sexual  indulgence,  but  particularly  the  former,  are  prolific  sources 
of  continued  palpitation.  We  see  also  those  affected  with  it 
who,  addicted  to  laborious  studies,  give  their  minds  no  rest, 
and  grudge  themselves  the  necessary  time  for  food,  sleep,  and 
exercise.  Women  ^\•ho  are  hysterical,  or  wdiose  uterine  functions 
are  disordered,  suffer,  or  fancy  that  they  suffer,  from  palpitation. 
So  do  so-called  nervous  people  invariably  complain  of  the  beating 
at  the  heart. 

In  those  whose  blood  is  much  impoverished,  the  palpitations 
are  often  severe  and  constant,  and  they  imagine  themselves  to 
be  laboring  under  an  incurable  disease.  There  is,  indeed,  from 
the  strong  resemblance  to  an  organic  affection,  apparent  cause 
for  alarm.  The  heart  strikes  sharply  and  abruptly  against  the 
walls  of  the  chest ;  its  action  is  frequent ;  the  breathing  becomes 
hurried  on  the  slightest  exertion.  Nay,  even  the  physical  signs 
may  be  those  of  a  structural  lesion.  The  altered  blood  gives 
rise  to  a  blowing  sound  in  the  heart,  which  is  transmitted  into  the 
carotid  and  subclavian  arteries.  The  difficulty  of  diagnosis  is  at 
times  considerable.  The  age ;  the  sex ;  the  anaemic  look ;  the 
presence  of  a  continuous  humming  sound  in  the  veins  of  the 
neck ;  the  strict  synchronism  of  the  murmur  ^\'ith  the  impulse ; 
its  want  of  harshness ;  its  seat  commonly  at  the  base  of  the  heart, 
— furnish  a  clue  to  the  nature  of  the  case.  Still,  we  liave  often 
to  judge  as  much  or  more  by  the  absence  of  the  signs  of  cardiac 
enlargement,  and  of  impediment  to  the  flow  of  the  blood,  whether 
the  heart  be  affected  in  its  valvular  apparatus,  or  whether  it  be 
simply  functionally  disturbed  and  circulating  watery  blood. 

A  troublesome  kind  of  palpitation  is  that  attended  with  marked 
irregularity  of  the  action  of  the  heart,  displaying  itself  by  the 
beat  being  noAV  slow,  now  fast,  or  occasionally  intermitting.  Suf- 
ferers from  lithsemia  or  gout,  or  old  persons  with  feeble  digestion, 


DISEASES   OP   THE   HEART.  403 

are  particularly  liable  to  it.  This  form  of  palpitation  is  not 
without  danger.  It  is  very  prone  to  be  associated  with  an  altera- 
tion in  the  structure  of  the  heart,  such  as  flabbiness  of  the  walls, 
which  may  not  be  sufficient  to  yield  any  distinctive  physical  signs, 
but  which  is  nevertheless  sufficient  to  be  a  source  of  apprehension. 

Some  who  experience  fits  of  palpitation  faint  away  during  them. 
But  the  almost  complete  suspension  of  the  movements  of  the 
heart  which  characterizes  an  attack  of  syncope  has  no  definite 
connection  with  any  form  of  palpitation,  nor,  indeed,  with  any 
form  of  cardiac  disorder,  organic  or  functional.  In  those  who 
are  subject  to  attacks  of  palpitation  or  to  irregular  action  of  the 
heart,  the  organ  may  finally  become  enlarged. 

A  peculiar  kind  of  irregular  action  of  the  heart  has  been  much 
discussed  under  the  name  of  hemisystole.  Leyden  pointed  out 
that  there  were  cases  in  which  with  every  two  beats  of  the  heart 
only  one  beat  of  the  pulse  was  felt,  and  attributed  this  to  the 
rio;ht  ventricle  alone  contracting  alternatelv  with  the  left.  Dif- 
ferent  explanations  have  been  given  of  the  fact  by  different  au- 
thors, but  the  observations  of  Riegel  and  Lachmann,  while  they 
do  not  strictly  confirm  the  alternate  action  of  the  ventricles  as 
the  cause  of  the  phenomenon,  point  to  irregular  contraction  of  the 
muscles  of  the  heart  as  the  cause.* 

We  sometimes  meet  with  a  singular  form  of  functional  disturb- 
ance of  the  heart  which  leads  to  textural  changes,  and  to  which 
Graves  called  particular  attention.  It  consists  in  a  long-continued 
excitement  of  the  organ,  as  evidenced  by  its  increased  force  and 
rapid  and  irregular  action,  which  is  followed  by  a  swelling  of  the 
thyroid  gland,  pulsation  of  the  arteries  of  the  neck,  and  promi- 
nence of  the  eyeballs.  This  disease,  exophthalmic  goitre,  is  most 
commonly  observed  in  females,  and  connected  with  hysteria,  neu- 
ralgia, or  uterine  disturbance ;  and  is  considered  to  be  due  to  an 
affection  of  the  cervical  sympathetic  nerve.  All  the  signs  may 
remit  or  may  become  aggravated  from  time  to  time,  and  especially 
during  a  severe  attack  of  palpitation.  The  turgescence  of  the 
thyroid  gland  arises  quite  independently  of  the  usual  exciting 
causes  of  bronchocele.     It  is  accompanied  by  a  pulsating  thrill 

*  Virchow's  Archiv,  Bd.  xliv. ;  Deutsclies  Arch.  f.  Kliu.  Med.,  Bd.  ssvii. 
p.  393. 


404  MEDICAL   DIAGNOSIS. 

similar  to  that  of  an  ancurismal  varix,  and  hv  a  distinct  throb. 
At  ah  advanced  period  of  the  comiiUiint,  these  signs  subside,  and 
the  gland  becomes  more  solid.  Indeed,  the  whole  atl'cction  may 
disappear,  and  the  gland,  the  eyes,  the  beat  of  the  carotids,  the 
action  of  the  heart,  may  all  be  brought  back  to  a  normal  condi- 
tion. On  the  other  hand,  hypertrophy  and  dilatation  may  result 
from  the  cardiac  })alpitations.  And  the  malady  may  be  noticed 
in  association  with  valvular  disease,  under  circumstances  which 
make  it  a  question  whether  this  has  followed  it  or  is  a  mere  con- 
comitant. 

The  protrusion  of  the  eyeball  is  often  combined  with  a  symp- 
tom that  Graefe  particularly  observed, — a  want  of  agreement  be- 
tween the  movement  of  the  lid  and  the  raising  or  depressing  of 
the  glance.  The  spasm  of  the  elevator  of  the  upper  eyelid  is 
held  by  Abadie*  to  be  pathognomonic.  Another  symptom  of  im- 
portance is  trembling  of  the  hands.  This  tremor,  Charcot  points 
out,  affects  the  whole  hand,  but  not  the  individual  fingers.  There 
is  also,  as  Charcot  has  shown,  greatly-lessened  bodily  resistance 
to  the  galvanic  current.  Less  constant  symptoms  are  moderate 
elevation  of  temperature,  sensation  of  heat,  increased  sweating, 
glycosuria,  migraine,  and  mental  derangement.  All  the  physical 
manifestations  of  the  disease  are  double-sided  ;  and  this,  with 
the  unchanged  state  of  the  pupils,  serves  to  distinguish  it  from 
those  rare  cases  described  by  Eulenberg,t  where  a  thyroid  groAvth 
pressing  on  the  sympathetic  on  one  side  produces  most  of  the 
symptoms  of  exophthalmic  goitre,  including  the  palpitations. 

In  the  distinction  from  ordinary  goitre,  the  absence  of  eye 
and  heart  symptoms  is  of  most  value.  There  is  also  no  murmur 
heard  over  the  enlarged  thyroid  gland ;  whereas  in  Graves'  dis- 
ease a  continuous  murmur  there  is  most  common,  and  is,  indeed, 
looked  upon  by  Guttmann  as  of  the  greatest  diagnostic  importance, 
especially  aiding  us  in  those  doubtful  cases  in  which  the  exoph- 
thalmos is  wanting.     My  own  experience  confirms  this  statement. 

There  is  another  form  of  functional  disorder  of  the  heart,  so 
peculiar  as  to  demand  a  special  notice.  It  is  the  curious  cardiac 
malady  of  which  we  saw  so  many  examples  in  soldiers  during  our 
civil  war,  and  to  which  I  gave  the  name  of  "  irntabk  heart,'^  and 

*  La  France  Medicale,  vol.  ii.,  1881.  f  Ziemssen's  Cyclopasdia. 


DISEASES   OF   THE   HEAET.  405 

which  we  also  find  occurring  in  private  life.  Its  main  symptoms 
are  habitual  frequency  of  the  action  of  the  heart,  constantly-recur- 
ring attacks  of  palpitation,  and  pain  referred  to  the  lower  por- 
tion of  the  prsecordial  region.  The  palpitations  come  on  (;hiefly 
during  exercise,  but  may  also  take  place  when  the  patient  is  quiet, 
and  in  many  cases  happen  most  often,  or  indeed  entirely,  at  night, 
thus  interfering  with  sleep.  Those  who  are  subject  to  the  disorder 
complain  much  of  headache  and  of  dizziness,  and  especially  of 
being  thus  affected  when  suffering  from  palpitation.  The  pain 
is  generally  dull  and  constant,  but  is  often  also  described  as  shoot- 
ing, and  as  taking  place  only  in  paroxysms.  Its  chief  seat  is  near 
the  apex,  and  it  is  combined  commonly  with  excessive  cutaneous 
sensibility.  Often  there  is  pain  nowhere  else  in  the  body  ;  but  in 
some  instances  the  cardiac  distress  is  associated  with  pain  in  the 
back,  which  itself  is  not  unusually  connected  with  the  excretion 
of  oxalate  of  lime  by  the  kidneys. 

The  action  of  the  heart  is  very  rapid,  and  in  many  instances  its 
rhythm  is  irregular.  The  impulse  is  slightly  extended,  but  not 
forcible,  like  that  of  hypertrophy  :  it  is  rather  abrupt  and  jerky. 
As  a  rule,  to  which  I  have  met  with  but  few  exceptions,  the 
sounds  of  the  heart  are  modified  as  follows :  the  first  sound  is 
short,  sometimes  sharp,  resembling  the  second  sound ;  at  other 
times  it  is  extremely  deficient  and  hardly  recognizable ;  the  dis- 
tinctness of  the  second  sound  is  much  heightened.  We  either 
hear  no  murmurs  in  the  heart  or  in  the  neck,  or  they  are  incon- 
stant. The  area  of  percussion  dulness  does  not  appear  to  be 
augmented.  The  pulse  is  almost  always  easily  compressible ;  it 
may  or  may  not  share  the  character  of  the  impulse.  It  is  usually 
very  much  influenced  by  position,  falling  rapidly  twenty  beats  or 
more  when  the  erect  posture  is  exchanged  for  the  recumbent.  The 
increased  frequency  of  beat  is  not  connected  with  increased  fre- 
quency of  respiration,  for  often  with  a  pulse  of  one  hundred  the 
respirations  scarcely  exceed  twenty  in  the  minute.  The  disorder 
is  very  obstinate,  and  improvement  comes  but  slowly. 

The  cause  of  the  morbid  cardiac  impressibility  is  difficult  to 
ascertain.  It  seems  in  many  instances  to  have  followed  fatiguing 
marches ;  in  some  it  occurred  after  fevers  or  diarrhoea ;  it  was  not 
connected  with  scurvy,  or  with  the  abuse  of  tobacco.  That  it  was 
not  due  to  anaemia,  was  proved  by  the  general  aspect  of  the  men, 


406  MEDICAL   DIAGNOSIS. 

which  was  often  that  of  ruddy  health.  For  a  fuller  consideration 
of  the  subject  I  refer  to  observations  elsewhere  detailed.* 

These,  then,  are  the  principal  varieties  of  functional  disorder 
of  the  heart.  It  is  hardly  necessary  again  to  state  that  the  phys- 
ical signs  present  the  most  certain,  if  not  the  only,  means  of  dis- 
tinguishing the  functional  from  the  structural  affection.  They 
show  us  tliat  neither  the  size  of  the  organ,  nor  its  sounds,  with 
the  exceptions  above  mentioned,  are  materially  different  from 
what  they  are  in  health. 

The  irritable  heart  just  described,  as  indeed  other  forms  of 
functional  heart  disorder,  may  pass  into  organic  cardiac  disease  by 
the  constant  overaction  of  the  heart.  And  overadion  or  strain  may 
also,  as  I  have  proved  in  the  publications  just  referred  to,  lead  to 
valvular  affection,  sometimes  by  preceding  hypertrophy,  at  other 
times  by  a  slow  process  of  inflammation  or  disorganization  engen- 
dered at  or  near  the  seat  of  the  valve.  Of  this  I  published  several 
instances  in  the  "  Memoirs  of  the  Sanitary  Commission."  Others 
have  been  brought  forward  by  Dr.  Allbuttf  which  happened 
among  persons  engaged  in  vocations  requiring  sustained  and  oft- 
reijeated  muscular  effort, — such  as  lifters,  smiths,  sawyers.  And 
in  his  elaborate  monograph  SeitzJ  has  detailed  several  fatal  cases 
in  which  the  symptoms  of  a  fatigued  heart,  due  to  strain,  were 
followed  by  extensive  dilatation  without  valvular  disease.  Ley- 
den,  too,  has  added  to  our  accurate  knowledge  of  the  subject.§ 


OEGATsHC   DISEASES   OF   THE   HEAET. 
Organic  diseases  of  the  heart  may  be  classified  as  follows : 

Organic  Diseases  of  tHe  Heart. 

Diseases  affecting  the  walls  of  the  heart,   ^  Hypertrophj-. 
and   mostly   changing   the   si^e   of   the  J   Dilatation. 
cavities.  (.  Atrophy. 

*  Medical  Memoirs  of  the  U.  S.  Sanitary  Commission,  1867  ;  American  Jour- 
nal of  the  Medical  Sciences,  .January,  1871 ;  and  the  Third  Toner  Lecture,  1874, 
"  On  Strain  and  Overaction  of  the  Heart." 

t  St.  George's  Hospital  Keports,  1872. 

J  Die  Ueheranstrengung  des  Herzens,  1875. 

^  Die  Herzkraukheiten  in  Folge  von  Ueberanstrengung,  Berlin,  1886. 


DISEASES   OF   THE   HEART.  407 

C  Fatty  degeneration. 
I   Malformations. 
I    Jlupture  of  the  heart. 
Diseases  affecting  chiefly  the  walls  alone.  J   j^^^^j.-^^^  ^nd  wounds. 


{ 


Aneurism  of  the  heart. 
New  growths  and  parasites. 
Endocarditis. 
Pericarditis. 


Diseases  affecting  the  pericardium. 


Concrenital  diseases. 


!of  membranes 
of  muscular  , 

structure.  {  Myocarditis  (Carditis). 

Diseases  of  the  valvular  apparatus |  Valvular  diseases. 

Chronic  pericarditis. 

Hydropericardium. 

Hsemopericardium. 

Pneumo-hydropericardium. 

New  formations  on  pericardium. 

Abnormal  positions. 

Closure  of  openings  of  right 
heart. 

Opening  between  the  ventricles. 

Narrowing  and  closure  of  pul- 
monary artery,  etc. 

These  are  the  organic  diseases  of  the  heart,  save  the  rarest.  But 
let  ns  study  the  cardiac  maladies  according  to  their  symptoms  and 
signs  rather  than  according  to  their  anatomical  classification. 

Acute  Diseases  presenting  Pain  in  the  Cardiac  Eegion;  the 
Symptoms  of  a  Disturbed  Circulation ;  and  a  Change  in  the 
Sounds  of  the  Heart,  or  their  Eeplacement  by  Murmurs. 

All  the  acute  affections  of  the  heart  come  under  this  head.  In 
all,  the  sounds  are  either  changed  in  their  character  or  are  replaced 
by  murmurs.  This  is  certainly  true  of  the  only  acute  diseases  of 
which  we  have  an  accurate  knowledge, — endocarditis  and  peri- 
carditis. All  the  acute  disorders  give  rise,  further,  to  more  or  less 
pain,  and  to  anxiety  of  expression  ;  in  all  there  is  fever  ;  all  are 
prone  to  occur  in  connection  with  other  morbid  conditions,  and 
especially  with  a  contaminated  state  of  the  blood.  In  all,  more- 
over, the  symptoms  of  a  disturbed  circulation  are  met  Avith  :  pal- 
pitation, irregular  action  of  the  heart,  deranged  flow  of  blood 
through  the  capillaries  of  different  organs,  and  a  tendency  to 
dropsical  accumulations.    That  these  symptoms  are  not  so  clearly 


408  MEDICAL   DIAGNOSIS. 

defined  as  in  some  of  the  chronic  cardiac  maladies,  is  owing  to  the 
shorter  time  the  coin]>laint  lasts. 

Acute  Endocarditis. — Acute  inflammation  of  the  lining 
membrane  of  the  heart  arises  from  exposure  to  cold,  or  without 
any  cause  being  discoverable.  It  sometimes  resnlts  from  violent 
efforts,  or  from  blows  or  other  injuries  to  the  chest.  It  is  often 
connected  with  a  vitiated  condition  of  the  blood,  as  in  pyaemia,  in 
puerperal  fever,  in  Bright's  disease,  or  in  diabetes.  But  its  most 
frequent  asst)ciation  is  with  acute  articular  rheumatism. 

The  chief  source  of  danger  in  endocarditis  is  the  tendency  the 
inflammation  has  to  limit  itself.  It  is  confined  to,  or  is  most 
strikingly  developed  at,  a  part  which  bears  least  of  all  any  im- 
pairment,— at  the  valves, — and  often  leaves  behind  it  some  perma- 
nent disorganization  of  their  delicate  structure.  But  it  does  not 
generally  affect  the  entire  valvular  apparatns :  that  of  the  left  side 
is  usually  alone  the  seat  of  disease.  What  morbid  anatomy  thus 
teaches,  explains  the  occurrence  and  situation  of  the  principal 
sign  by  which  endocarditis  is  recognized.  The  roughness  of  the 
surface  over  which  the  blood  flows,  or  the  lymph  deposited  on  or 
in  the  neighborhood  of  the  valves,  interfering  with  their  function, 
occasions  a  distinct  murmur,  which  is  mostly  confined  to  the  mitral 
and  aortic  openings. 

Besides  this  bloAving  sound,  there  are  other  signs  worthy  of 
note.  It  is  true,  they  do  not  form  so  leading  a  feature  of  the 
disease;  still,  they  aid  in  its  correct  appreciation.  The  excited 
heart  beats  with  augmented  force,  and  sometimes  with  great  ir- 
regularity, as  the  not  unusual  doubling  of  the  second  sound  at 
the  base  proves.  The  size  of  the  organ  is  not  notably  increased, 
except  in  those  cases  in  which  its  cavities  are  choked  with  blood 
or  fibrin-clots.  The  pulse  corresponds  to  the  action  of  the  heart; 
yet  not  so  closely  as  might  be  expected.  It  is,  for  the  most  part, 
frequent  and  strong,  and  rather  forcible  at  first;  sometimes  it  is 
small  and  frequent.  It  becomes  irregular,  one  beat  being  strong, 
the  next  weak,  if  the  circulation  through  the  heart  be  seriously 
obstructed.  But  it  may  be  feeble  while  the  heart  is  thumping 
with  violence  against  the  walls  of  the  chest.  Occasionally  at  the 
onset  of  the  attack  it  has  been  observed  to  be  slower  than  natural. 

The  general  symptoms  are  not  always  uniform.  There  is  usu- 
ally a  sense  of  uneasiness  around  the  heart,  with  a  fever  having 


DISEASES   OF   THE   HEART.  409 

a  temperature  ranging  from  101°  to  103°,  a  short  cough,  diffi- 
culty of  breathing,  and  an  extreme  anxiety  depleted  on  the  coun- 
tenance. To  these  are  not  uncommonly  added  turgescenee  of  the 
face,  headache,  some  wandering  of  the  mind,  a  yellowish  hue 
of  the  skin,  gastric  irritability,  diarrhoea,  and  rigors,  followed  by 
sensations  of  heat.  Excessive  pain  in  the  heart  is  rare,  and  is 
not  likely  to  happen  unless  the  pericardium  or  the  muscular 
walls  be  implicated.  In  some  cases  an  eruption  of  subcutaneous 
fibrous  nodules  occurs,  especially  in  the  rheumatic  endocarditis  of 
children. 

Now,  where  these  symptoms  are  present;  where  they  manifest 
themselves  in  one  whose  system  is  in  a  state  in  which  endocarditis 
is  apt  to  take  place ;  and  where  they  are  accompanied  by  a  blow- 
ing sound  recently  and  rather  suddenly  developed, — we  are  cer- 
tain that  inflammation  is  working  its  changes  in  the  lining  mem- 
brane of  the  heart.  Yet  some  circumspection  is  requisite  before 
arriving  at  this  conclusion,  and  before  the  patient  is  subjected  to 
energetic  treatment  with  the  view  of  saving  him  from  the  sup- 
posed damage  which  his  heart  is  about  to  undergo.  A  murmur 
may  be  attended  with  febrile  signs  and  not  be  dependent  upon 
acute  endocarditis.  The  sound  may  be  of  organic  origin;  or  it 
may  be  engendered  in  the  course  of  an  idiopathic  fever,  and  the 
lining  membrane  of  the  heart  be  unaltered. 

In  the  first  instance  the  murmur  is  old,  and  results  from  some 
chronic  injury  to  the  valve,  the  attending  fever  being  an  accidental 
complication.  Here  is  undoubtedly  a  difficult  case  for  diagnosis. 
"VVe  see  the  patient  for  the  first  time;  he  has  fever;  his  heart 
is  acting  strongly;  a  distinct  blowing  sound  is  perceived  over  it. 
How  are  we  to  tell  that  his  complaint  is  not  acute  endocarditis  ? 
We  have  no  absolute  means  of  deciding  that  it  is  not.  Yet  by 
careful  inquiry  we  can  usually  come  to  a  knoMdedge  of  the  truth. 
If  the  patient  do  not  recollect  to  have  suffered  previously  from 
dyspnoea,  palpitation,  or  other  signs  of  an  affection  of  the  heart ; 
if  the  cardiac  excitement  and  irritation  be  well  defined ;  if  the 
face  denote  distress;  if  the  accompanying  symptoms  indicate  a 
state  which  is  prone  to  be  complicated  with  endocardial  inflam- 
mation,— it  is  this  disease  under  which  he  is  laboring.  I  may 
add  another  and  very  important  element  of  distinction  deduced 
from  the  study  of  the  blowing  sound,  to  wit,  that  the  murmur  of 


410  MEDICAL   DIAGNOSIS. 

endocarditis  is  not  so  rough,  is  not  often  heard  during  the  dis- 
tention of  the  heart,  and  may  be  changeable  in  its  seat,  which  an 
okl-standing  nuinnur  never  is.  Besides,  it  is  not  associated  with 
those  signs  of  enlargement  which  are  invariably  found  when  the 
valves  have  been  for  any  length  of  time  affected,  unless  the  acute 
inHannnatiou  occur  in  a  heart  the  valves  of  Avhich  have  been 
previously  spoiled.  Under  such  circumstances,  we  can  only  con- 
jecture what  is  going  on  within  the  organ  from  its  increased  ex- 
citement, and,  if  I  ma}'  take  my  own  experience  as  the  general 
rule,  from  the  character  of  the  blowing  sound  being  altered.  It 
is  rendered  often  less  distinct,  nay,  it  is  even  entirely  muffled, 
by  the  products  of  the  recent  inflammation. 

But  how  are  we  to  distinguish  between  the  soft  murmur  arising 
in  the  course  of  fevers,  and  that  resulting  from  eifused  lymph? 
It,  too,  is  not  rough.  It,  too,  happens  with  the  impulse.  It,  too, 
is  preceded,  as  some  cases  of  endocarditis  are,  by  a  lengthening  of 
the  first  sound.  Here  is  assuredly  a  strong  resemblance ;  yet  by 
no  means  an  identity.  The  blowing  sound  in  fevers  does  not 
exist  until  the  blood  is  profoundly  altered.  In  endocarditis  it 
takes  place  almost  as  soon  as  the  disease  begins, — certainly  as  soon 
as  we  are  able  to  recognize  positively  its  beginning.  The  heart 
in  fevers  may  be  softened,  but  it  is  not  so  directly  disturbed  in  its 
action.  We  do  not  find  those  symptoms,  local  as  well  as  general, 
which  show  that  the  circulation  is  obstructed.  The  blowing  sound 
is  rarely  at  the  apex,  but  more  over  the  body  of  the  heart.  To 
this  some  weight  may  be  attached,  since  the  murmur  of  endocar- 
ditis is  very  apt  to  be  heard  at  the  apex.  But  to  no  fact  ought  as 
much  weight  to  be  attached  as  to  the  one  first  mentioned,  that  the 
murmur  takes  place  early  and  not  late  in  the  disease. 

Throughout  this  description  of  endocarditis,  only  simple,  un- 
complicated cases  have  been  kept  in  view ;  yet  it  is  not  often  that 
the  malady  is  seen  in  so  pure  a  type.  It  is  more  generally  accom- 
panied by  the  friction  sounds  and  other  signs  of  acute  pericarditis, 
and  bv  the  swollen  joints,  the  painful  movements,  the  acid  per- 
spirations, of  acute  rheumatism  ;  or  by  the  characteristic  appear- 
ances on  the  skin  of  erythema  marginatum;  or  by  the  kidney 
svmptoms  of  Bright's  disease,  or  the  evidences  of  pysemia  or 
septicaemia. 

Nor  is  a  murmur  in  endocarditis  invariable.     If  the  question 


DISEASES   OF   THE   HEART.  411 

be  asked,  "Can  endocarditis  occur  without  a  blowing  sound?" 
it  must  be  answered  in  the  affirmative.  When  the  seat  of  the 
inflammation  is  not  near  the  valves,  no  murmur  is  generated. 
There  may  be  also  none  if  no  vegetations  exist  on  the  valves,  and 
perhaps  in  states  of  the  exudation  with  which  we  are  at  present 
unacquainted.  We  cannot,  under  such  circumstances,  detect  an 
attack  of  endocarditis.  Yet  it  may  be  even  then  strongly  sus- 
pected to  be  present  if  great  excitement  and  irritation  of  the 
heart  manifest  themselves  in  a  person  who  is  laboring  under  a 
disease  which  predisposes  to  endocardial  inflammation,  such  as 
rheumatism.  Cases  of  this  nature  are,  however,  exceptional. 
They  do  not  happen  sufficiently  often  to  invalidate  the  statement 
that  the  development  of  a  murmur  is  the  sign  indicative  of  endo- 
carditis. Still,  they  happen  sufficiently  often  to  impress  upon  us 
that  our  knowledge  of  endocarditis  is  not  complete. 

The  clinical  study  of  endocarditis  is,  in  truth,  a  comparatively 
recent  study.  There  are  some  points  about  it  which  are  as  yet 
unknown,  and  others  which  have  not  been  long  cleared  up.  To 
this  class  belong  the  interesting  researches  on  the  formation  of 
clots  of  fibrin  in  the  heart,  and  on  the  effects  produced  when  they 
or  the  vegetations  which  stud  the  valves  are  washed  into  the  cir- 
culation. The  formation  of  clots  in  the  cardiac  cavities,  if  at  all 
extensive,  announces  itself  by  a  sudden  appearance  or  a  sudden 
augmentation  of  the  symptoms  of  obstructed  circulation  :  the  skin 
is  cold,  and  the  surface  may  be  bluish ;  there  is  a  struggle  for 
breath,  the  pulse  is  frequent  and  feeble,  the  action  of  the  heart 
becomes  exceedingly  irregular,  its  sounds  are  indistinct,  or  a  more 
or  less  distinct  murmur  is  heard,  and  the  extent  of  the  prsecordial 
percussion  dulness  is  somewhat  increased.  Great  anxiety  of  coun- 
tenance, nausea,  vomiting,  excitement  of  the  nervous  system  and 
delirium,  turgid  veins  in  the  neck,  and  fits  of  fainting,  are  also 
among  the  manifestations  of  the  clogged  flow  of  blood  through 
the  heart.  Yet  these  phenomena  are  not  absolutely  distinctive ; 
for  Walshe  records  that  the  effects  of  a  rupture  of  a  sigmoid 
valve  or  of  a  tendinous  cord,  during  the  acute  endocardial  disease, 
will  give  rise  to  symptoms  exactly  similar  to  the  obstruction  of 
the  circulation  resulting  from  polypoid  concretions  in  the  heart. 

Portions  of  the  clots,  or  of  the  vegetations  on  the  valves,  are 
sometimes  washed  into  the  current,  and  the  embolism  occasions 


412  MEDICAL   DIAGNOSIS. 

symptoms  which,  before  we  were  aware  of  tlio  damages  to  which 
the  dotaolied  masses  may  give  rise,  appeared  inexi)licable.  But 
now — when  we  see  the  circuhition  speedily  diminished  or  arrested 
in  a  limb,  and  the  limb  becoming  painful,  swelling,  or  beginning 
to  mortify  ;  when  we  find  that  the  flow  of  the  blood  through  the 
brain  has  become  suddenly  disturbed,  and  the  nuiscles  of  one  side 
drop  paralyzed  ;  when  the  difficult  breathing  becomes  rapidly  still 
more  difficult,  while  there  are  no  signs  of  a  superadded  affection 
of  the  luug,  nay,  while  the  power  fully  to  expand  the  lungs  re- 
mains unimpaired,  or  while  an  effusion  of  fluid  into  the  air-vesi- 
cles follows  the  dyspnoea — we  know  what  has  happened  :  we  know 
that  a  broken-otf  piece  of  fibrin  has  been  driven  into  the  artery  of 
the  limb,  or  into  the  brain,  or  into  the  branches  of  the  pulmo- 
nary artery,  and,  being  too  large  to  go  any  farther,  has  stuck  fast, 
and  has  given  rise  to  all  these  sudden  and  sad  consequences. 
Sad  indeed  they  are;  for,  even  if  the  plugs  do  not  lead  to  an 
immediately  fatal  result,  they  are  apt  to  lay  the  groundwork  for 
structural  alterations  in  any  organ  or  tissue  in  M'hich  they  become 
impacted. 

But  let  it  not  be  understood  that  the  detachment  of  vegetations 
from  the  valves,  or  of  fragments  of  clot  formed  in  the  cavities  of 
the  heart,  happens  in  endocarditis  only.  Pieces  may  be  separated 
from  valves  that  are  in  a  state  of  so-called  ossification.  And  the 
blood  in  the  heart  may  clot  from  any  interference  with  the  ciu-rent, 
from  heart  palsy,  or  from  changes  in  the  vital  fluid  wholly  uncon- 
nected with  inflammation.  But  when  it  coagulates,  from  what- 
ever cause,  the  symptoms  are  the  same  as  those  just  described.  A 
murmur,  too,  is  not  uncommonly  produced,  which  is  not  distin- 
guishable from  that  due  to  endocardial  inflammation,  but  which  is 
not  of  long  duration,  since  death  generally  follows  the  impediment 
in  the  heart  in  a  few  days  at  farthest. 

Inflammation  of  tJie  aorta  may  occasion  many  of  the  symptoms 
of  acute  endocarditis ;  at  all  events,  it  may  do  so  ^vhen  the  upper 
part  of  the  aorta  is  implicated.  But  it  cannot  be  said  that  it  is  a 
condition  which  with  certainty  may  be  discriminated.  The  most 
significant  signs  are  hurried  respiration,  a  sharp,  rapid  pulse,  tu- 
multuous action  of  the  heart,  pain  in  the  precordial  region,  often 
severely  increased  by  movements,  and  also  felt  along  the  course 
of  the  spine,  and  a  loud  systolic  blowing  sound.     When  the  ab- 


DISEASES   OF   THE    HEART.  413 

dominal  aorta  is  affected,  there  is  a  strong  local  pulsation,  and  a 
marked  murmur  will  be  heard  with  greatest  distinctness  at  or  near 
the  seat  of  the  inflammation.  In  some  cases  of  aortitis,  Bright* 
noticed  an  extremely  high  degree  of  morbid  sensibility  over  all 
parts  of  the  body,  which  caused  the  patient  to  scream  with  pain 
when  his  wrists  were  merely  touched.  The  disorder  is  most 
apt  to  haj^pen  in  cachectic  persons ;  and  it  has  been  repeatedly 
observed  in  those  attacked  with  erysipelas,  or  after  operations  and 
injuries.! 

There  is  a  form  of  endocarditis  which  may  be  here  briefly 
mentioned, — ulcerative  endocarditis.  It  is  not  common  in  this 
country,  although  I  have  seen  instances  of  the  malady.  It  oc- 
curs mostly  in  connection  with  low  forms  of  rheumatism  or  with 
blood-poisoning,  and  the  symptoms  of  this,  or  of  pyaemia  or  a 
low  septic  fever,  are  apparently  the  prominent  features  of  the  case, 
or  it  may  happen  subsequently  to  pneumonia.^  The  ulceration 
perforates  the  valves,  and  may  extend  into  the  muscular  structure 
of  the  heart ;  pneumonia  or  pleurisy,  embolic  formations,  and  in- 
farcts and  metastatic  abscesses  in  various  parts  of  the  body  are 
among  the  common  attendants.  The  perilous  affection  shows  an 
endocarditis  with  the  ordinary  physical  signs  developing  amidst 
the  symptoms  of  profound  blood-poisoning  and  prostration,  al- 
though these  physical  signs  may  be  masked  by  a  pericardial  com- 
plication. Marked  and  recurring  chills,  like  those  of  malarial 
fever,  but  coming  on  irregularly  ;  a  temperature  of  105°  to  107°  ; 
an  extremely  rapid  pulse,  becoming  suddenly  much  slower,  though 
very  irregular ;  profuse  sweats ;  vertigo ;  delirium  followed  by 
stupor ;  dry  tongue ;  vomiting  and  diarrhoea ;  jaundice ;  tender- 
ness over  liver  and  spleen ;  and  scanty,  albuminous  urine, — are 
among  the  prominent  features  of  the  malady.  As  regards  the 
thoracic  symptoms,  there  may  be  oppression,  dyspnoea,  and  pain, 
as  ordinarily  in  endocarditis,  yet  these  symptoms  may  be  wholly 
wanting.  In  some  instances  a  peculiar  diffused  rose  rash,  here 
and  there  mixed  with  papules  and  spots  of  ecchymosis,  is  noticed. 
By  some,  ulcerative  endocarditis  is  looked  upon  as  diphtheritic ; 


*  Guy's  Hospital  Keports,  vol.  i. 

I  Chevers,  ib.,  vol.  vi.,  and  2d  Series,  vol.  i. 

X  Arch,  de  Physiol.,  August,  1886. 


414  MEDICAL    DIAGNOSIS. 

certainly  when  it  has  happened  during  puerperal  fever  dii)htheritic 
exudations  liave  been  found  on  the  mucous  membrane  of  the 
vagina  and  uterus.  It  is,  indeed,  certain  that  micro-organisms 
are  constantly  present,  and  are  found  not  only  in  the  heart,  but 
also  in  the  infarcts  in  the  spleen  and  liver  which  are  common 
in  the  atiection.  Death  is  the  common  ending, — either  from 
gradual  exhaustion,  or  suddenly  by  the  tearing  away  of  the 
injured  valves. 

The  disease  is  one  of  middle  age,  and  is  extremely  rare  in  chil- 
dren. It  is  more  often  mistaken  for  typhoid  fever  than  for  any 
other  disease.  But  it  is  also  mistaken  for  typhoid  pneumonia, 
for  ccrebro-spinal  fever,  and  for  hemorrhagic  smallpox.  When 
ulcerative  endocarditis  happens  in  connection  with  malarial  poison- 
ing, a  not  infrequent  association  in  Africa,  its  seat  of  predilection 
is  in  the  aortic  valves.* 

Acute  Pericarditis.  —  Acute  inflammation  of  the  serous 
membrane  of  the  exterior  of  the  heart  is  very  similar  to  that 
of  its  interior.  It  is  developed  under  the  same  circumstances. 
It  exhibits  the  same  frequent  association  with  rheumatism  ;  it 
presents  the  same  symptoms.  Nature  has  not,  indeed,  drawn  a 
very  strict  line  of  demarcation  between  the  two  diseases.  When 
one  exists,  the  other  is  very  apt  to  attend  it.  Yet  we  do  meet 
with  endocarditis  without  pericarditis,  and  more  often  still  with 
pericarditis  without  endocarditis. 

The  anatomical  eifects  of  inflammation  of  the  pericardium  are 
like  those  of  acute  endocarditis,  and  resemble  still  more  closely 
those  which  inflammation  of  the  adjoining  serous  membrane — 
the  pleura — occasions.  The  pericardium  becomes  injected  and 
dry ;  plastic  lymph  accumulates  on  its  surfaces,  and  especially 
on  the  surface  which  fits  tightly  around  the  heart.  This  stage 
of  the  disease  corresponds  to  the  dry  stage  of  acute  pleurisy.  It 
may  have  the  same  termination  by  the  two  roughened  surfaces 
adhering.  But  it  is  often  followed  by  a  stage  similar  to  that  of 
pleural  effusion.  The  bag  in  which  the  heart  lies  is  filled  with 
fluid ;  the  effusion  may  remain  stationary  or  be  absorbed,  and  the 
rugged  portions  of  the  membrane  be  placed  again  in  apposition. 

From  a  knowledge  of  the  anatomical  changes,  the  physical 

*  Lancereaux,  Arch.  Gen.  de  Med.,  April,  1881. 


DISEASES   OF   THE    HEART. 


415 


sio-ns  may  be  foretold.  It  is  obvious  that  there  must  be  at  first  a 
friction  sound  ;  that  then  the  fluid  which  distends  the  pericardium 
will  increase  the  area  of  percussion  dulness  over  the  heart,  and 
prevent  the  sounds  and  the  impulse  from  being  distinctly  per- 
ceived. But  the  friction  sound  is  not  always  the  same  in  extent 
or  in  character,  because  the  deposited  lymph  is  not  always  the 
same  in  extent  or  in  character.      The  sound  is  like  the  crumpling 

Fig.  34, 


Illustration  of  the  position  of  the  heart  in  pericarditis,  and  of  the 
distention  of  the  pericardium  with  fluid.  The  heart-sounds  are  in- 
distinct, except  above  the  effusion ;  the  impulse  is  feeble.  The 
extent  and  shape  of  the  percussion  dulness  maj'  be  judged  of  by  the 
appearance  of  the  distended  sac. 


of  parchment,  or  the  creaking  of  new  leather,  or  it  is  grazing,  or 
like  a  series  of  irregular  clicks.  It  is  a  single  or  it  is  a  double 
sound,  and  is  prone  to  mask  the  natural  sounds  of  the  heart. 
But  these  are  all  points  which  have  been  already  described :  we 
shall  merely  add  that  when  the  friction  develops  itself  under  our 
observation,  and  with  signs  of  excitement  of  the  heart,  it  is  as 
distinctive  of  inflammation  of  the  pericardium  as  a  recent  blow- 
ing sound  is,  under  the  same  circumstances,  distinctive  of  inflam- 


416  MEDICAL    DIAGNOSIS. 

mation  of  the  endocardium.  When  the  pericardial  effusion  takes 
place,  it  ceases ;  but  only  gradually,  and  not  always  coni])letely  ; 
and  in  any  case  it  is  not  uncommon  for  the  ear  still  to  recognize 
the  murmur  at  the  base  of  the  heart  and  around  the  origin  of  the 
great  vessels. 

The  percussion  dulness  due  to  the  effusion  is  generally  consid- 
erable ;  and  its  contour  is  characteristic.  As  the  fluid  gravitates 
to  the  lower  portion  of  the  sac,  this  distends,  of  necessity,  more 
than  the  part  where  the  pericardium  adheres  to  the  vessels.  The 
consequence  is  that  the  dulness,  when  the  patient  is  in  the  erect 
posture,  is  pyramidal ;  when  he  lies  on  his  back,  or  changes  from 
side  to  side,  the  outline  of  the  flat  sound  is  somewhat  altered. 
Rotch,*  in  an  elaborate  inqniry  into  the  matter,  points  to  the 
dulness  in  the  fifth  intercostal  space  to  the  right  of  the  sternum 
as  occurring  even  in  small  effusions,  and  as  an  available  diag- 
nostic sign  ;  and  Iloberts,t  in  his  excellent  monograph,  speaks 
of  the  valuable  aid  afforded  by  it  to  surgeons  about  to  tap  the 
pericardium. 

In  cases  of  considerable  efFnsion,  the  intercostal  spaces  of  the 
cardiac  region  widen,  the  eye  recognizes  a  distinct  bulging,  and 
the  dulness  on  percussion  reaches  to  the  second,  or  even  to  the 
first,  rib.  Within  the  space  of  dulness  is  sometimes  seen  an  ir- 
regular, wavy  motion;  and  what  the  eye  detects,  the  hand  feels. 
Yet  no  movements,  or  only  slight  movements,  may  be  perceptible 
in  the  prsecordia.  The  heart,  W'ith  its  point  pushed  upward  by 
the  accumulating  liquid,  has  to  struggle  to  reach  the  walls  of  the 
chest.  Its  contractions  are  irregular;  its  impulse  is  feeble,  or  all 
appreciable  impulse  has  ceased.  The  sounds  heard  through  the 
mass  of  fluid  seem  distant  and  muffled.  Yet  the  second  sound 
over  the  upper  part  of  the  sternum  and  at  the  base  of  the  heart 
retains  its  sharpness. 

During  the  stage  of  absorption  the  apex  returns  to  its  nor- 
mal position;  the  dulness  gradually  disappears;  the  sounds  and 
the  invpulse  regain  more  of  their  normal  character;  the  friction 
murmur  reappears,  and  then  ceases,  leaving  frequently  the  two 


*  Boston  Med.  and  Surg.  Journ.,  1878,  vol.  xcix. ;  also  article  "  Diseases  of 
the  Pericardium,"  in  Keating's  Cyclopredia  of  the  Diseases  of  Children,  vol.  ii. 
f  Paracentesis  of  the  Pericardium,  Phila.,  1880. 


DISEASES    OF    THE    HEART.  417 

surfaces  of  the  pericardium  glued  together, — a  condition  wliicli  is 
not  harmless,  since  it  not  unusually  leads  to  dilated  hypertroj^hy, 
or  to  dilatation. 

"We  cannot  foretell  how  long  it  will  take  for  the  disease  to  run 
through  its  different  stages.  Death  may  occur  in  less  than  thirty 
hours,  the  heart  being  paralyzed  by  an  enormous  effusion;  on  the 
other  hand,  the  acute  attack  may  last  for  as  many  days,  and  then 
leave  serious  traces.  But  whatever  stage  the  malady  be  in,  it  can 
be  recognized  only  by  the  physical  signs  just  detailed:  by  the 
friction,  the  peculiar  percussion  dulness,  the  enfeebled  impulse  and 
heart-sounds. 

There  are  no  general  symptoms  that  prove  a  pericarditis  to 
exist.  There  are  symptoms  by  which  we  may  infer  that  peri- 
carditis is  present;  but  there  are  none  which  absolutely  belong  to 
it  and  Avould  prevent  it  from  being  overlooked.  The  symptoms 
usually  met  with  are  those  of  inflammation  of  the  endocardium, 
but  with  more  decided  local  evidence  of  disorder.  We  find  the 
anxious  expression;  the  fever;  the  oedema;  the  same  uncertain 
or  irregular  pulse.  But  there  is  more  pain  over  the  heart, — acute, 
severe  pain,  shooting  to  the  left  shoulder,  augmented  by  move- 
ment, increased  by  pressure;  there  is  more  dyspnoea,  because  the 
distended  sac  presses  on  the  lung;  a  dry,  irritative  cough;  and 
sometimes  difficulty  in  swallowing.  Yet  every  one  of  these  symp- 
toms may  be  absent.  The  pulse  may  be  regular;  the  breathing 
not  perceptibly  accelerated,  or  laborious ;  and  even  the  symptom 
regarded  as  the  most  important  of  all — the  pain — may  be  wanting 
from  the  beginning  to  the  end  of  the  disease. 

When  the  action  of  the  heart  grows  weaker  and  weaker,  the 
circulation  becomes  more  irregular.  The  beat  of  the  artery  at 
the  wrist  is  feeble,  and  intermits;  the  veins  of  the  neck  are 
prominent;  the  skin  is  cold  and  pale;  the  extremities  are  oedem- 
atous.  These  are  always  symptoms  of  grave  import;  they  tell 
of  the  failing  power  of  the  heart,  and  call  for  agents  which  will 
sustain  it. 

If  next  we  inquire  with  what  complaints  acute  pericarditis  is 
likely  to  be  confounded,  inflammation  of  the  endocardium  and 
inflammation  of  the  pleura  occur  at  once  to  the  mind.  To  con- 
trast the  signs  of  the  first  two  maladies,  for  the  slight  difference 
in  their  symptoms  has  already  been  mentioned  : 

27 


418  MEDICAL   DIAGNOSIS. 

Endocarditis.  •  Pericarditis. 

Blowing  sound  ;  excited  action  of  the  Friction  sound ;  excited  action  of  the 

heart.        '  heart. 

Slight,  if  any,  increase  of  percussion  In  stage  of  eftusiun,  marked  and  ex- 

dulness.  tended  percussion  dulness. 

Impulse  strong.  Impulse  wavy  and  feehle. 

Sounds   normal  or   more  distinct,  ex-  Sounds  feeble  and  muffled,  except  at 

cept  at  site  where  murmur  is  heard.  base  ;  no  blowing  sound. 

Sneh  is  the  distinction  of  pure  cases  of  each  disease.  Still, 
as  already  stated,  the  affections  are  often  combined.  It  is  not 
nnconimon  to  hear  with  the  friction  sound  a  distinct  endocardial 
murmur.  But  there  is  sometimes  a  difficulty  of  another  kind  in 
the  way  of  a  precise  diagnosis.  The  murmur  produced  on  the 
outside  of  the  heart  may  simulate  so  closely  the  murmur  produced 
in  its  interior  that  it  is  almost  impossible  to  discriminate  between 
them.  The  former  may  completely  possess  the  blowing  characters 
of  the  latter.  Mostly,  however,  it  is  rougher ;  more  prone  to  be 
double  ;  and  each  division  is  like  the  other,  equally  rough,  equally 
superficial-sounding,  equally  lacking  in  strict  correspondence  to 
the  systole  or  to  the  diastole.  And,  above  all,  the  sound  alters 
at  times  both  in  situation  and  in  character  with  amazing  rapidity. 
Perceived  now  as  an  ordinary  bellows  murmur  on  the  left  side,  it 
is  after  the  lapse  of  some  hours  heard  as  a  rough  rasping  sound 
on  the  right.  These  changes  have  a  high  degree  of  value.  But 
they  are  not  of  constant  occurrence ;  and  to  say  that  it  is  some- 
times impossible  to  tell  a  pericardial  from  an  endocardial  sound 
is  to  say  no  more  than  is  borne  out  by  every-day  experience. 
In  the  stage  of  eifusion  pericarditis  is  not  likely  to  be  mistaken 
for  endocarditis. 

Pleurisy  gives  rise  to  some  of  the  same  symptoms  and  signs  as 
pericarditis.  It  develops  a  friction  sound  :  it  occasions  dulness  on 
percussion,  dyspnoea,  and  cough.  But  the  physical  signs  are  in 
different  situations.  In  one  disorder  they  are  in  the  region  of  the 
heart,  and  are  confined  there ;  in  the  other  they  are  spread  over 
the  whole  side  of  the  chest,  and  are  most  perceptible  at  the 
back.  This  is  true  of  the  dulness,  and,  for  the  most  part,  of  the 
friction  sound,  which,  when  of  pericardial  origin,  is  rarely  heard 
posteriorly. 

At  times,  however,  we  meet  with  very  puzzling  cases.     A  fric- 


DISEASES   OF   THE   HEART.  419 

tion  sound  discerned  over  the  heart  may  be  in  reality  produced 
in  the  adjoining  pleura.  The  patient  is  directed  to  suspend  his 
breathing.  The  friction  sound  does  not  stop.  Now,  the  inference 
from  this  would  be  that  the  sound  originates  in  .the  pericardium ; 
and  in  the  large  majority  of  instances  this  is  a  correct  inference. 
But  it  is  not  always  so.  The  friction  may  be  engendered  in  the 
pleura  and  be  caused  by  the  movements  of  the  heart.  To  men- 
tion an  example  :  a  laboring-man  was  attacked  with  acute  articu- 
lar rheumatism,  in  the  course  of  wjiich  a  friction  sound  was  heard 
over  the  outer  limit  of  the  left  ventricle,  and  also  posteriorly  over 
the  lower  portion  of  the  left  lung.  Occasionally  it  ceased  when 
the  patient  stopped  breathing,  and  during  a  few  beats  of  the  heart. 
Then  it  recommenced  with  unequal  intensity  while  the  respiration 
was  still  arrested.  It  is  evident  that  this  sound  could  not  have 
been  that  of  an  inflamed  pericardium ;  certainly  the  one  perceived 
anteriorly  was  not.  I  know  of  no  absolute  means,  besides  the 
intermission  of  the  sound  during  some  of  the  beats  of  the  heart, 
of  detecting  in  these  rare  cases  the  true  seat  of  the  disease. 

To  confound  the  dulness  on  percussion  caused  by  liquid  in  the 
pericardium  with  that  due  to  liquid  in  the  pleura,  is  a  mistake 
more  likely  to  happen,  because  the  two  serous  membranes,  and 
indeed  the  lung,  are  often  implicated  in  the  same  inflammation. 
But  a  pericarditis  uncomplicated  with  pleurisy  or  with  pleuro- 
pneumonia does  not  change  the  clear  sound  at  the  back  of  the 
chest  save  in  very  rare  cases  of  enormous  accumulation  of  fluid. 
Effiision  into  the  pleura  gives  rise  to  a  flat  sound  anteriorly ;  to  a 
still  more  perceptible  dulness  at  the  inferior  portion  of  the  chest 
posteriorly ;  and  the  sounds  of  the  heart  remain  unaltered,  unless 
its  investing  membrane  contain  fluid  also. 

These,  then,  are  the  diseases  with  which  acute  pericarditis  is 
liable  to  be  confounded.  There  are  several  'chronic  cardiac  mala- 
dies which  will  occasion  some  of  the  same  signs  and  symptoms : 
such  are  thinning  of  the  ventricles  with  distention  of  the  cavi- 
ties, and  a  dropsy  of  the  pericardium.  But  the  history  of  these 
affections  is  different,  and  their  signs,  although  similar,  are  not 
precisely  the  same.  The  dropsy  of  the  pericardium  is  associated 
with  dropsies  elsewhere,  and  with  some  obvious  cause  accounting 
for  the  watery  exudation,  and  at  no  stage  of  its  existence  does  it 
exhibit  a  friction  sound. 


420  MEDICAL    DIAGNOSIS, 

But  there  is  another  acute  complaint  of  which  pericarditis  some- 
times borrows  the  garb.  The  thoracic  symptoms  may  be  latent, 
but  the  disease  may  produce  the  symptoms  of  extreme  gastric 
in'itafion  or  inflaijmiation.  Tliere  are  nausea  and  vomiting,  and 
tenderness  on  pressure  in  the  epigastric  region.  All  the  remedies 
are  directed  to  the  stomach  ;  and  at  the  post-mortem  examination 
the  })hysician  stands  amazed  at  finding  this  viscus  healthy  and 
the  pericardium  full  of  serum  or  pus.  An  inquiry  into  the  state 
of  the  heart  might  have  saved  liim  from  a  serious  blunder. 

Another  grave  error  Avhich  may  be  thus  obviated  is  the  mis- 
taking of  some  cases  of  acute  pericarditis,  on  account  of  the  wild 
delirium  they  present,  for  acute  inflammation  of  the  brain.  Now, 
both  in  endocarditis  and  in  pericarditis  this  active  delirium  may 
throw  all  the  other  symptoms  into  the  background.  It  is  difficult 
to  see  why  a  pericardial  inflammation  should  give  rise  to  such  vio- 
lent disturbance  of  the  brain.  It  is  not  at  all  unlikely  that  it  has 
its  origin,  in  part,  at  least,  in  the  contaminated  state  of  the  blood 
which  occurs  in  the  affections,  as  rheumatism  or  Bright's  disease, 
with  which  pericarditis  is  often  associated.  However  occasioned, 
it  is  necessary  to  be  aware  that  the  cerebral  symptoms  arising  in 
inflammation  of  the  membranes  of  the  heart  may  entirely  draw 
off  attention  from  the  serious  lesions  within  the  chest.  A  fixed 
delusion  of  having  committed  some  crime  appears  to  Flint*  to 
be  a  distinguishing  feature  of  the  mental  wandering  ;  while  Sib- 
son  f  in  his  exhaustive  analysis  points  out,  what  I  have  known  to 
happen  in  more  than  one  instance,  that  the  desponding  and  taci- 
turn or,  as  he  calls  it,  sombre  delirium  lasts  from  two  or  three 
weeks  to  as  many  months. 

Can  we  by  the  symptoms  or  physical  signs  tell  the  character  of 
the  fluid  in  the  sac  ?  We  cannot  by  the  signs,  and  by  the  symp- 
toms we  can  only  suspect  pus  if  there  be  recurring  chills,  and 
irregular  but  high  temperature,  and  if  the  pericarditis  have  arisen 
in  the  course  of  a  malady  that  makes  the  presence  of  pus  likely. 
Hemorrhagic  pericarditis  can  also  only  be  distinguished  as  a  prob- 
ability by  the  history.  It  happens  in  scurvy  and  in  purpura, 
and  may  be  an  attendant  upon  cancer  of  the  pericardium. 

*  Diseases  of  the  Heart. 

f  Article  "  Pericarditis"  in  Keynolds's  System  of  Medicine. 


DISEASES   OF    THE    HEART.  421 

Before  dismissing  the  subject  of  pericarditis,  let  us  inquire  in 
how  far  one  of  its  terminations — by  adhesion  or  agglutination  of 
the  surfaces — can  be  recognized.  In  many  of  such  cases,  whether 
or  not  there  be  coexisting  dilatation,  or  hypertrophy,  or  that  rare 
condition,  cardiac  atrophy,  or  even  probably  when  the  heart  is  of 
normal  size,  we  find  changed  rhythm  and  dyspnoea.  Yet  these  are 
not  special  signs  of  pericardial  adhesion.  Nor  is  the  "  abrupt, 
jogging,  or  trembling  motion"  of  the  heart,  described  by  Hope, 
pathognomonic ;  nor  the  extinction  of  the  second  sound,  on  which 
Aran  dwells.  For  the  pericardial  surfaces  may  be  found  most 
thoroughly  glued  to  each  other  where  neither  of  these  signs  was 
present.  But  it  must  be  admitted  that  the  double  jog  is  often  seen, 
especially  if  the  enlargement  of  the  heart  be  at  all  extensive,  and 
that  enfeeblement  or  absence  of  impulse,  Avhile  it  may  happen,  is 
much  rarer.  Yet  there  is  not  a  single  symptom  or  sign  constant, 
or  characteristic  of  pericardial  adhesion.  The  most  trustworthy 
signs  are  those  given  by  Skoda  :*  a  drawing  up  of  the  heart's 
apex  during  the  contraction  of  the  ventricles,  with  a  depression  in 
the  intercostal  spaces  becoming  visible  at  the  same  time,  and  some- 
times with  a  simultaneous  sinking  in  at  the  lower  half  of  the. 
sternum ;  the  limits  of  the  dull  percussion  sound  remaining  un- 
affected during  inspiration  and  expiration  ;  and  a  confused  instead 
of  a  distinct  and  punctated  beat  of  the  impulse  against  the  finger. 
Gairdner,f  too,  lays  stress  upon  the  marked  movement  of  the  in- 
tercostal spaces  over  the  heart;  while  Waishe|  thinks  that  the 
systolic  dimpling  and  the  undulatory  movements  in  the  prsecordia 
only  happen  if  there  be,  in  addition  to  the  pericardial  adhesions, 
pleuritic  adhesions  in  front  of  the  organ,  or  if  the  agglutination 
of  the  pericardium  be  combined  with  cardiac  hypertrophy.  In 
the  latter  case,  too,  jogging,  trembling  action  of  the  heart  may  be 
highly  developed.  Friedreich!  has  called  attention  to  a  rapid 
emptying  of  the  veins  of  the  neck  during  the  diastole  of  the  heart, 
while  with  the  systole  they  swell  up;  and  Riess||  has  told  us  that, 
owing  to  the  close  bringing  together  of  the  heart,  diaphragm,  and 

*  Zeitschr.  der  k.  k.  Gesellsch.  der  Aerzte  zu  Wien,  April,  1852. 

f  Edinburgh  Medical  Journal,  1851,  1859,  etc. 

J  Diseai5es  of  the  Heart,  4th  ed.,  p.  244. 

§  Virchow's  Archiv,  Bd.  xxix. 

II  Berliner  Klinische  Wochenschrift,  No.  51,  1878. 


422  MEDICAL   DIAGNOSIS. 

stomach,  the  heart-sounds  ivsound  with  a  nictallie  ring.  When 
the  pericardial  surfaces  are  very  extensively  and  firmly  united,  the 
eye  is  struck  by  the  evident  depression  of  the  pravordial  region. 
AVhen  the  pericartlium  is  adherent  to  the  sternum  and  bands  pass 
off  compressing  the  aorta, — "indurated  mediastino-pericarditis," 
— a  pulse  vanishing  with  each  full  inspiration — jmlsus  paradoxus 
— has  been  described  by  Kussmanl,*  The  same  sign  has  been 
noticed  by  Irvine  in  cases  of  adherent  pericardium  and  pleura, 
and  by  Traubef  in  exudative  pericarditis  where  the  mediastinum 
was  not  implicated.  Aran  has  proved  the  tendency  to  sudden 
death  in  complete  pericardial  adhesion. 

Closely  connected  with  the  subject  of  inflammation  of  the 
pericardium  is  that'rai'C  affection  in  which  air  is  present  in  the 
pericardial  cavity,  pneumo-pcricardium,  or,  more  strictly  speaking, 
on  account  of  the  frequent  association  with  fluid,  pneumo-hj/dro- 
perlcarditdu.  It  occurs  as  the  result  of  injuries,  of  communication 
established  by  disease  between  the  pericardium  and  the  neigh- 
boring organs,  and  in  very  exce^Dtional  instances  is  due  to  decom- 
position of  licjuids  in  the  sac.  Its  chief  diagnostic  features  are 
abnormal  resonance  over  the  cardiac  region,  and  a  metallic  char- 
acter of  the  heart-sounds.  The  tympanitic  resonance  alters  in  a 
most  marked  manner  with  changes  in  the  posture  of  the  patient, 
and  is  limited  by  a  distinct  line  of  dulness  caused  by  the  fluid. 
The  metallic  sounds  may  at  times  be  heard  at  a  distance,  and 
may  be  attended  with  sounds  of  most  extraordinary  kind,  friction 
sounds  mixed  with  splashing  and  gurgling,  the  so-called  water- 
w^heel  sound,  the  bruit  de  moulin  ;  generally  an  intermittent  sound, 
at  first  metallic,  which  Reynier|  has  informed  us  has  not  a  bad 
prognostic  meaning,  except  when  the  pericardium  is  not  intact,  as 
in  cases  of  traumatic  opening.  The  symptoms  of  pneumo-pericar- 
dium  are  vague,  generally  those  of  a  pericarditis,  with  great  diffi- 
culty in  breathing  and  failing  circulation.  In  point  of  diagnosis 
we  must  be  careful  to  take  all  the  symptoms  and  signs  into 
account,  and  not  be  misled  by  the  modification  of  the  cardiac 
sounds  and  the  splashing  and  metallic  phenomena  due  to  a  dilated 
stomach.     From  pneumothorax,  even  when  encapsulated  near  the 

*  Berliner  Klinische  Wochenschrift,  No.  37,  1873. 

t  Charite  Annalen,  1876.  J  Arch.  Gen.  de  Med.,  May,  1880. 


DISEASES    OF    THE    HEART.  423 

heart,  we  distinguish  pneumo-pcricardium  by  the  dulness  on  per- 
cussion to  be  found  over  the  displaced  heart  in  the  former  malady, 
and  the  amphoric  or  metallic  respiratory  sounds  that  arc  heard  in 
addition  to  the  metallic  heart  sounds. 

The  entrance  of  air  may  happen,  as  in  the  cases  of  Meigs*  and 
of  Muller,t  by  a  rupture  brought  about  by  the  pericardial  exuda- 
tion,— in  the  one  case  into  the  oesophagus,  in  the  other  into  the 
lung.     These  cases  of  ulcerative  perforation  almost  all  end  fatally. 

Myocarditis.-^The  substance  of  the  heart  itself  undergoes  at 
times  inflammation.  Of  this  there  are  several  varieties,  two  of 
which  are  the  most  distinctive, — the  acute  inflammation  of  the 
muscular  walls,  and  the  chronic  myocarditis  or  fibroid  degenera- 
tion of  the  heart.  The  acute  gives  rise  to  infiltration  among  the 
fibres  of  the  heart  of  blood-corpuscles,  of  granules  of  exudation, 
and  of  leucocytes,  and  local  softening  and  circumscribed  abscesses, 
and  even  gangrene  and  perforation  of  the  ventricle,  may  result. 
But,  though  familiar  with  the  post-mortem  appearances,  we  are 
not  enabled  to  foretell  the  state  of  the  heart  during  life,  mainly 
because  the  muscular  structure  is  rarely  affected  without  the  endo- 
cardium, or  still  more  frequently  the  pericardium,  being  impli- 
cated, and  thus  the  manifestations  of  these  disorders  occur  mixed 
up  with  those  of  the  carditis.  On  analyzing  the  cases  on  record, 
I  cannot,  indeed,  find  either  a  symptom  or  a  sign  which  can  be 
considered  as  in  the  least  pathognomonic.  Extreme  pain  in  the 
cardiac  region  is  the  most  usual  and  the  most  prominent  of  the 
symptoms.  It  is  sometimes  excruciating  and  sharp,  at  other  times 
dull,  yet  distressing  and  constant.  The  breathing  is  generally 
much  oppressed ;  delirium  is  often  present ;  the  skin  becomes 
cold ;  the  heart  fails  in  power ;  and  the  patient  dies  in  a  state 
of  utter  prostration  or  appears  to  suifocate.  The  pulse,  as  in 
endocarditis  or  in  pericarditis,  exhibits  no  uniform  character. 
The  statement  that  it  is  invariably  intermittent,  feeble,  and  quick, 
is  not  correct.  It  is  so  as  the  disease  advances,  but  it  has  been 
reported  to  be  full,  and  not  above  eighty,  long  after  the  distress 
in  the  chest  Avas  unbearable.  J    Extreme  rapidity  with  great  weak- 

*  Amer.  Journ.  Med.  Sci.,  Jan.  1875. 

I  Deutsches  Archiv  fiir  Klinische  Medicin,  Bd.  xxiv.,  1879. 
X  Salter,  Medico-Chirurgical  Transactions,  vol.  xxii.     In  several  of  tlie  cases 
on  record,  for  instance  in  the  one  mentioned  by  Graves  in  his  Cliuicai  Lectures, 


424  MEDICAL    DIAGNOSIS. 

net^s  of  tlie  pulse  is,  Fotlieroill *  has  told  us,  probably  the  most 
trustworthy  sign  of  acute  myocarditis  wheu  extensive  and  ditfuse. 
The  signs. of  cardiac  failure  are  quickly  developed.  In  purulent 
myocarditis  the  temperature  shows  marked  remissions  and  exacer- 
bations, and  rigors  and  sweatings  are  usual. f  Acute  myocarditis 
may  occur  in  rheumatism,  but  it  is  most  common  in  pyaemia  and 
phlebitis.     In  children  there  is  a  distinctly  cerebral  form.| 

Chronic  myocarditify,  or  fibroid  degeneration,  often  results  from 
rheumatism,  or  attends  j^scudo-hypcrtrophic  paralysis.  A  very 
common  cause  is  disease  of  the  coronary  arteries,  especially  ob- 
literating endarteritis  of  syphilitic  origin.  The  disease  is  most 
common  in  men,  and  may  lead  to  aneurism  of  the  heart.  The 
diagnosis  of  chronic  myocarditis  is  as  uncertain  as  that  of  the 
acute  form.  The  symptoms  are  those  of  a  feeble  heart :  oedema, 
great  dyspnoea,  cough,  hemorrhages  into  different  organs,  venous 
congestions,  have  been  especially  noted.  In  some  cases  there  is 
pain  over  the  heart.  The  percussion  dulness  in  the  cardiac 
region  is  somewhat  increased.  The  first  sound  is  indistinct,  the 
second  over  the  aorta  very  weak.  The  most  characteristic  sign 
is  a  Avant  of  correspondence  between  the  heart  and  the  pulse-beats ; 
these  are  unequal  and  irregular. §  Some  stress  may  be  laid  on  the 
signs  of  pericardial  adhesions,  if  present. 


Oliromc  Diseases  attended  witli  Increased  Extent  of  Percussion 
Dulness,  but  with  Normal  or  almost  Normal  Heart-Sounds. 

We  often  meet  with  a  group  of  affections  which  present  the 
phenomena  of  extended  dulness  on  percussion  in  the  cardiac 
region,  associated  Avith  sounds  like  those  heard  in  health  :  they 
may  be  louder  or  less  loud,  better  defined  or  less  well  defined,  still 
they  are  the  natural  sounds  of  the  heart,  and  no  cardiac  murmur 
is  detected,  unless  the  disorder  be  no  longer  uncomplicated. 

there  was  coexisting  valvular  disease,  which,  of  course,  invalidates  the  statements 
as  regards  the  character  of  the  pulse,  and  indeed  as  regards  many  of  the  other 
symptoms. 

*  Diseases  of  the  Heart,  2d  ed.,  1879. 

t  Bramwell,  Diseases  of  the  Heart,  Edinb.,  1884. 

X  Mitchell  Bruce,  Keating's  Cycloptedia  of  the  Diseases  of  Children,  vol.  ii. 

I  Euhle,  Archiv  fiir  Klin.  Med.,  1878. 


DISEASES   OF   THE    HEART.  425 

To  this  group  belong  those  diseases  which  affect  the  \valls  of 
the  heart  or  its  cavities,  without  having  involved  the  valvidar 
apparatus,  such  as  hypertrophy  and  dilatation, — types  of  tlic  two 
different  states  of  force  and  of  weakness,  but  both  exhibiting 
an  extent  of  percussion  dulness  greater  than  in  health,  and  heart- 
sounds  not  materially  changed. 

Hypertrophy. — Hypertrophy  of  the  heart  is  an  overgrowth 
of  its  walls,  and  usually  also  of  its  cavities ;  for,  although  we 
may  have  the  muscle  thickening  without  the  cavity's  enlarging, 
nay,  even  with  its  diminishing  in  size,  neither  this  sim^jle  nor  the 
concentric  hypertrophy  occurs,  save  in  rare  instances.  It  is  evi- 
dent that  any  one  of  the  chambers  of  the  heart  may  alone  become 
hypertrophied.  But,  practically,  the  state  we  mean  when  speak- 
ing of  cardiac  hypertrophy  is  an  increase  of  the  ventricles,  and 
especially  of  the  left  ventricle,  in  its  wall  and  cavity,  with  a  simi- 
lar, although  much  slighter,  expansion  of  the  right  side.  Whether 
the  auricles  be  enlarged  or  not,  is  a  matter  always  more  of  conjec- 
ture than  susceptible  of  proof. 

The  physical  and  vital  manifestations  of  the  heart  having  out- 
grown its  natural  dimensions  are  these.  The  pulse  is  full  and 
strong,  and  somewhat  tense.  The  face  is  florid,  or  else  it  is  pale ; 
and  the  mucous  membranes  of  the  lips  and  eyelids  are  injected. 
The  eyes  are  bright,  and  apt  to  be  prominent.  The  carotids  pul- 
sate forcibly  under  the  least  excitement.  Some  persons  suffer 
from  headache  and  giddiness ;  in  fact,  all  the  symptoms  denote  a 
circulation  actively,  too  actively,  carried  on.  Yet  the  symptoms 
directly  referable  to  the  heart  are  not  marked.  There  is,  as  a 
rule,  no  pain  or  irregular  action  of  the  heart,  nor  do  violent  fits  of 
palpitation  occur.  What  the  patient  comes  to  consult  his  physi- 
cian about,  are  rushes  of  blood  to  the  head ;  or  a  ringing  in  the 
ears;  or  a  feeling  of  weight  in  the  epigastrium  which  troubles 
him  after  a  full  meal:  or  shortness  of  breath;  or  in  consequence 
of  the  powerful  action  of  the  heart,  when  lying  in  bed,  attracting 
his  attention ;  or  because  he  is  alarmed  about  a  dry  cough,  and 
believes  himself  the  victim  of  pulmonary  consumption. 

The  physical  signs  are  mor^  uniform  than  the  symptoms.  We 
observe  a  fulness  or  arching  of  the  prsecordial  region,  and  an 
impulse,  strong,  heaving,  and  extended  over  several  intercostal 
spaces.     The  apex  does  not  strike  the  chest-walls  between  the  fifth 


426 


MEDICAL   DIAGNOSIS. 


and  sixth  ribs,  but  its  beat  is  perceived  lower  down,  usually  an 
inch  or  more  to  the  outside  of  the  nipple  line.  The  extent  of 
percussion  dulness  increases,  both  longitudinally  and  transversely; 
and  particularly  in  the  latter  direction,  if  the  right  ventricle  be 
much  enlarged.  This  peculiarity  in  the  expansion  of  the  area  of 
dulness  on  percussion  forms,  in  truth,  with  the  greater  dyspnoea. 


K>(^\<^V<V^ 


An  lij'pertropbied  heart  lying  in  its  position  in  tlie  chest.  The  cause  of  the 
lowererl  apex  beat,  and  of  tlie  extension  of  the  Impulse,  as  well  as  of  the 
somewhat  squarer  outline  of  the  increased  dulness  over  the  enlarged  organ, 
is  obvious  from  the  shape  and  position  of  the  heart. 

and  with  an  impulse  more  directly  perceived  over  the  right  side 
of  the  heart,  near  the  pit  of  the  stomach,  and  often  out  of  propor- 
tion to  the  compressible  and  rather  small  radial  beat,  and  with 
the  increased  distinctness  of  the  second  sound  of  the  pulmonary 
artery,  the  sign  that  hypertrophy  with  dilatation  has  principally 
affected  the  right  side. 

The  first  sound  of  an  hypertrophied  heart  is  duller  than  in 
health,  but  prolonged  and  weighty.  The  second  sound  is  not 
particularly  changed.     There  are  no  murmurs,  except  under  rare 


DISEASES   OF   THE   HEART.  427 

circumstances,  which  will  be  mentioned  in  discussing  valvular  dis- 
eases. Thus,  the  greatest  value  of  auscultation  is  that,  Vjy  showing 
the  sounds  but  little  altered,  it  enables  us  positively  to  exclude 
a  lesion  of  the  valves;  just  as  the  chief  service  of  percussion, 
Avith  reference  to  an  enlarged  heart,  consists  in  permitting  us  to 
distinguish  the  excited  motions  of  the  simply  disturbed  organ 
from  the  action  of  a  heart  the  walls  of  which  are  thickened ;  and 
as  the  main  use  in  noting  the  impulse  is  that  it  serves  as  a  means 
of  discrimination  between  hypertrophy  and  those  affections  in 
which  the  beat  is  weakened,  such  as  dilatation,  or  a  pericardial 
effusion,  or  between  the  dulne.ss  in  the  prsecordial  region  due 
to  hypertrophy  and  that  caused  by  deposits  in  the  pleura  or  the 
lung. 

Hypertrophy  may  be  combined  with  dilatation  of  the  heart. 
This  hypertrophy  with  dilatation  presents  a  less  dull,  prolonged 
first  sound,  and  the  pulse,  though  full,  is  likely  to  be  more  com- 
pressible. Hypertrophy  may  affect  specially  any  part  of  the  con- 
stituents of  the  muscular  walls.  Thus,  the  connective  tissue,  as 
Quain  has  specially  called  attention  to,  may  be  alone  concerned 
in  the  morbid  action.  Hypertrophy  of  the  heart  is  found  much 
more  frequently  among  males  than  among  females.  Its  causes  are 
various.  It  is  common  in  Bright's  disease  ;  continued  functional 
excitement  produces  it ;  so  does  any  kind  of  strain  and  overaction, 
and  perhaps  excessive  nourishment.  But  the  main  cause  is  an 
obstruction  to  the  circulation,  either  in  the  heart  or  in  other  organs. 
It  is  for  this  reason  that  the  complaint  is  so  often  met  with  in  con- 
nection with  diseases  of  the  valves  or  of  the  large  arteries,  and 
that  the  right  side  of  the  heart  enlarges  when  the  pulmonary  air- 
vesicles  are  overdistended.  We  also,  as  we  have  seen,  encounter 
hypertrophy  of  the  heart  as  a  consequence  of  the  obliteration  of 
the  pericardial  sac  by  its  two  surfaces  adhering. 

There  is  a  form  of  hypertrophy  of  the  heart  to  which  atten- 
tion has  been  particularly  called  by  Fothergill's  description, — the 
so-called  gouty  heart  Generally,  although  not  always,  there  is 
coexisting  disease  of  the  kidney  of  the  chronic  contracting  form. 
In  the  first  stage  of  the  affection,  when  well  marked,  we  find  de- 
cided hypertrophy  with  accentuation  or  booming  of  the  second 
aortic  sound,  high  blood-pressure,  tense  pulse,  hardened  arteries, 
and  the  passage  of  large  amounts  of  pale  urine  of  low  specific 


428  MEDICAL   DIAGNOSIS. 

gravity.  The  renal  clianiies  may  ov  may  not  be  evident ;  we  may 
or  may  not  detect  albumen  in  the  urine.  In  a  subset^uent  stage  of 
the  malady  there  is  I'ailure  ot"  the  circulation,  and  witii  the  signs 
of  the  heart-failure,  very  often  going  hand  in  hand  with  fatty 
degeneration,  the  bulk  of  urine  diminishes  and  the  renal  affection 
becomes  more  marked.  The  cardio-vaseular  phenomena  are  early 
made  perceptible  by  the  sphygmograph.  The  full,  tense  pulse 
gives  a  full  up-stroke,  a  broad  summit,  and  a  retarded  down- 
stroke ;  the  "square-headed  tracing"  formed  is  very  characteristic 
of  the  malady,  and  bespeaks  the  fibroid  change  in  the  kidney, 
whether  or  nut  albumen  be  found.  In  some  instances  there  is 
considerable  dilatation  as  well  as  hypertrophy,  and  then  severe 
palpitations  result.  The  high  blood-pressure  is  due  to  the  waste- 
laden  blood  ;  and  the  defective  nutrition  is  apt  to  show  itself  also 
in  atheromatous  arteries,  which  in  part  account  for  the  sj>hygmo- 
graphic  tracings.  The  skin  oftcns  exhibits  little  twigs  of  dilated 
vessels  ;  the  ear  is  usually  deep  red,  with  a  large  glistening  lobe ; 
or  in  spare  persons  the  lobe  looks  withered  ;  the  teeth  become 
blunt  and  worn  down  in  time ;  the  hair  is  apt  to  be  iron-gray. 
There  is  the  history  of  gout,  acquired  or  hereditary,  but  there 
may  have  been  no  active  outbreak  of  gout,  rather  the  condition 
of  imperfect  assimilation  and  increased  uric  acid,  known  as 
lithaemia. 

Dilatation. — Dilatation  of  the  heart  is  the  reverse  of  hyper- 
trophv.  By  this  it  is  not  meant  that  because  the  cavities  are  dilated 
the  walls  may  not  be  increased.  But  it  is  meant  that  the  morl)id 
condition  in  which  the  cavities  have  been  stretched  out  of  all  pro- 
portion to  the  thickness  of  the  muscular  walls  is  the  reverse  of 
the  condition  in  which  the  walls  are  stronger,  firmer,  and  more 
powerful  than  in  health ;  in  other  words,  the  latter  state  is  very 
different  from  the  former,  and  when  it  predominates  we  call  the 
affection  hypertrophy ;  when  the  former  is  in  excess  we  speak  of 
the  disease  as  dilatation,  no  matter  whether  the  walls  be  slightly 
thicker  than  normal,  or  of  natural  thickness,  or  thinner,  and 
apparently  hardly  capable  of  supporting  the  weight  of  the  blood. 

From  these  almost  opposite  pathological  states,  almost  opposite 
physical  signs  or  symptoms  might  be  expected.  And  so  we  find 
it.  In  dilatation  we  look  in  vain  for  the  activity  and  power  with 
which  the  blood  is  forced  out  of  an  hypertrophied  heart.    Eveiy- 


DISEASES   OF   THE   HEART.  429 

thing  indicates  inaction  and  stagnation.  There  is  a  strong  ten- 
dency to  venous  congestions  and  to  dropsies.  The  portal  system 
is  gorged.  The  liver  increases  in  size.  The  bowels  are  consti- 
pated. The  urinary  secretion  is  interfered  with,  and  sometimes 
albumen  is  passed.  The  hearing  may  become  dull.  The  patient 
is  languid  and  feeble,  and  his  intellect  obtuse.  He  suffers  from 
chilly  sensations,  and  from  uneasiness  in  the  cardiac  region  and 
palpitations.  The  pulse  is  small  and  irregular,  and  the  veins  of 
the  surface  are  swollen.  The  skin  around  the  ankles,  and  often 
at  other  parts  of  the  body,  pits  on  pressure.  But,  since  it  is  the 
right  side  of  the  heart  which  is  usually  the  most  affected,  the 
lungs  show  most  plainly  the  effects  of  the  venous  stagnation. 
Difficulty  in  breathing,  making  itself  at  times  manifest  in  parox- 
ysms attended  with  wheezing  respiration  ;  a  chronic  cough ;  a 
collection  of  serum  in  the  pulmonary  structure, — all  add  to  the 
misery  which  the  perilous  malady  entails.  And  as  it  is  commonly 
some  obstructive  disease  in  the  lungs,  such  as  emphysema,  "which 
has  given  rise  to  the  dilatation  of  the  right  side  of  the  heart,  so 
this  again  augments  the  morbid  state  of  the  lungs,  and  aggravates 
the  symptoms. 

The  physical  signs  are  very  unlike  those  of  hypertrophy.  The 
same  extended  clulness  on  percussion  exists ;  but  it  is  associated 
with  a  feeble  and  fluttering  impulse,  which  is  in  strong  contrast 
with  the  heaving,  powerful  blow  of  an  hypertrophied  left  ventri- 
cle. The  sounds  are  not  always  the  same.  When  the  walls  are 
thin,  they  are  clearer,  sharper,  and  more  ringing  than  in  health  : 
if,  however,  the  muscular  structure  be  at  all  disorganized,  the 
first  sound  is  faint  and  very  ill  defined.  But  no  murmurs  are 
perceived,  unless  a  watery  state  of  the  blood  produces  them, 
or  unless  it  happens — and  it  does  not  un frequently  happen — that 
the  dilatation  of  the  heart  is  conjoined  to  valves  incompetent, 
either  temporarily  or  permanently,  to  prevent  regurgitation. 

Such  is  the  description  of  cases  of  marked  dilatation.  All  cases 
are  not,  however,  so  distinct,  nor  are  they  uncomplicated.  Or- 
ganic affections  of  the  heart  are,  indeed,  indefinitely  blended,  and 
dilatation  is  met  with  in  different  combinations  and  in  every  pos- 
sible degree.  Accordingly,  its  symptoms  and  signs  are  somewhat 
dissimilar.  But  one  constant  feature  it  certainly  preserves  :  it 
always  holds  up  to  view  both  the  vital  and  the  physical  manifes- 


430 


MEDICAL   DIAGNOSIS. 


tations  of  a  weak  heart.  Indeed,  when  an  hypertrophicd  heart 
dilates,  the  signs  of  relative  weakness  become  superadded,  the 
impulse  is- not  so  strong  as  before  in  comparison  with  the  percus- 


FlG. 


A  dilated  lieart,  the  right  ventricle  opened.  In  this  case  there  was 
no  valvular  disease.  Hence  the  chiiracteristic  pliysical  signs;  the  in- 
creased dnlness  on  percussion,  the  extended  hut  weak  impulse.  The  first 
sound  was  feeble,  for  the  organ  was  soft  as  well  as  dilated. 

sion  dulness,  and  dropsy  becomes  a  marked  symptom.  Pure 
dilatation  is  likely  to  be  confounded  with  the  diseases  in  which 
enfeebled  action  of  the  heart  is  encountered,  and  these  are  fatty 
degeneration  and  a  pericardial  effusion. 

Fatty  Degeneration. — This  is  one  of  those  disorders  with 
the  anatomical  characters  of  Avhich  we  are  far  better  acquainted 
than  with  their  clinical  history.  The  microscope  has  revealed  to 
us  that  the  soft  flabby  heart,  Avhich  appears  to  the  eye  little 
changed  from  health,  has  had  its  muscular  fibres  atrophied  and 
transformed  into  fat-granules  and  oil.  It  has  thus  explained  to 
us  why  a  heart  seemingly  so  little  altered  should  rupture,  or  why 
death  should  set  in  with  all  the  evidences  of  failing  circulation, 
when  nothing  in  the  whole  body  can  be  found  sufficiently  diseased 
to  account  for  the  termination  of  the  vital  action.     But  our  power 


DISEASES   OF   THE   HEART.  431 

to  recognize  the  fatty  change  during  life  has  not  kept  pace  with 
our  power  to  recognize  it  after  death.  There  is  as  yet  no  sign 
discovered  by  which  we  can  positively  say  that  the  dangerous  dis- 
organization of  the  muscular  fibres  of  the  heart  is  in  progress. 
We  may,  liowever,  suspect  it,  if  tlie  signs  of  weak  action  of  the 
heart — feeble  impulse  and  ill-defined  sounds — coexist  with  oppres- 
sion, with  a  tendency  to  coldness  of  the  extremities,  with  a  pulse 
permanently  slow  or  permanently  frequent  and  irregular,  and  be 
met  with  in  a  person  who  is  the  subject  of  gout  or  of  a  wasting 
disease,  or  is  very  intemperate,  or  has  arrived  at  a  time  of  life  at 
which  all  the  organs  are  prone  to  undergo  decay.  Something 
more  than  a  suspicion  is  warranted  if,  in  addition,  there  be  proof 
of  atheromatous  c;hange  in  the  vessels,  or  of  fatty  degeneration 
elsewhere,  such  as  an  arcus  senilis  /"^  or  if  it  be  ascertained  that 
the  patient  suffers  from  pain  across  the  upper  part  of  the  sternum 
and  from  paroxysms  of  severe  pain  in  the  heart;  that  he  sighs 
frequently ;  that  he  is  easily  put  out  of  breath ;  that  his  skin  has 
a  yellow,  greasy  look ;  that  he  is  subject  to  syncope,  or  to  seizures 
during  which  his  respiration  seems  to  come  to  a  stand-still ;  and 
that  he  is  liable  to  vertigo,  or  to  be  stricken  down  with  repeated 
attacks  having  the  character  of  apoplexy,  save  that  they  are  not 
followed  by  paralysis. 

Now,  here  are  certainly  a  group  of  phenomena  dissimilar  to 
those  of  a  dilated  heart.  Let  us  add  that  the  extent  of  the  cardiac 
percussion  dulness  remains  unaltered,  except  in  those  instances  in 
which  some  hypertrophy  coexists,  that  dropsies  and  local  conges- 
tions are  not  prominent  symptoms,  or  indeed  do  not  happen  at 
all,  and  the  dissimilarity  becomes  still  greater.  A  differential 
diagnosis  would,  under  such  circumstances,  be  anything  but  diffi- 
cult. But  in  point  of  fact  the  matter  is  generally  not  so  easily 
decided,  and  there  are  several  reasons  why  it  is  not.  One  is,  that 
all  the  features  described  are  rarely  combined  in  the  same  case ; 
indeed,  some  of  the  more  marked,  such  as  the  "  Cheyne-Stokes 

*  But  the  arcus  senilis  may  be  absent.  Fothergill  points  out  that  there  is  a 
true  and  a  false  arcus.  The  former  alone  is  significant  of  fatty  degeneration 
and  tissue-decay.  It  is  a  ring  around  the  cornea  of  yellowish  hue  with  blurred 
outlines,  and  the  cornea  itself  is  cloudy.  The  false  form  occurs  in  elderly  per- 
sons as  an  evidence  of  calcareous  degeneration  ;  the  ring  is  well  defined,  the 
central  part  of  the  cornea  is  clear  and  bright. 


432  MEDICAL   DIAGNOSIS. 

breathing,"  the  seizures  like  apoplexy,  are  uncommon  rather  than 
common,  anti  the  peculiar  breathing  occasionally  occurs  in  other 
cardiac  maladies.  The  second  is,  because  non-tatty  softening  may 
present  the  same  vital  and  ])liysi('al  manifestations.  The  third 
is,  because  a  tatty  heart  has  a  tendency  to  become  dilated,  and 
the  symptoms  and  signs  of  the  former  disease  are  then  merged 
into  the  symptoms  and  signs  of  tlie  latter,  throwing  us  back  for  a 
diagnosis  into  the  province  of  conjecture  and  probability.  With 
the  organ  in  such  a  condition,  the  practical  value  of  a  ditferential 
diagnosis  is,  however,  not  great ;  for  both  atfections  are  benefited 
by  the  same  treatment:  both  require  that  the  power  of  the  heart 
should  be  stistaincd. 

The  remarks  about  fatty  heart  apply  particularly  to  that  va- 
riety of  the  disorder  in  which  the  muscular  structure  in  middle- 
aged  or  elderly  persons  has  slowly  undergone  decay.  But  we 
also,  although  far  less  frequently,  meet  Avith  fatty  heart  in  young 
persons  and  in  a  more  acute  form  ;  we  encounter  it  in  chlorosis, 
in  pernicious  anaemia,  after  repeated  hemorrhages,  and  after 
phosphorus  poisoning.  Poisonous  doses  of  acids,  such  as  nitric, 
sulphuric,  oxalic,  are  said  by  Von  Dusch  also  to  give  rise  to  the 
cardiac  change. 

Persons  who  have  fatty  hearts  are  subject  to  attacks  of  faint- 
ness,  preceded  or  attended  with  sensations  of  great  coldness,  or  a 
chill.  Sometimes  these  attacks  happen  daily,  or  every  few  days, 
and  in  such  a  manner  as  to  give  rise  to  the  impression  that  they 
are  due  to  malaria.  A  number  of  instances  of  the  kind  have  come 
under  my  observation,  and  I  have  met  with  them  particularly  at 
the  end  of  fevers  or  other  debilitating  diseases  happening  in  those 
aifected  with  feeble  hearts.  The  seizures,  though  bearing  a  resem- 
blance to  intermittent  fever,  are  unlike  it  in  being  associated  with 
signs  of  great  weakness  of  the  circulation  or  heart  failure,  with 
sometimes  almost  a  vanishing  pulse  and  a  sense  of  impending  dis- 
solution; in  their  irregular  accession;  and  in  their  not  being  fol- 
lowed by  felu'ile  phenomena.  In  doubtful  cases  the  thermometer, 
by  showing  the  absence  of  the  great  rise  of  temperature  of  the 
malarial  disorder,  will  materially  assist  us  in  the  diagnosis. 

Heart   starvation,  to  which   Fothergill*  has  pointedly  called 

*  Edinburgh  Mod.  Journ.,  May,  1881. 


DISEASES    OF    THE    HEART.  433 

attention,  has,  in  the  feeble  circulation,  the  cold  extremities,  the 
tendency  to  vertigo,  and  the  pseudo-apoplectic  attacks,  symptoms 
common  with  those  of  fatty  heart.  But  there  is  not  a  true  arcus, 
nor  a  degenerate  skin,  and  the  cardiac  asthenia  is  found  earlier  in 
life,  and  is  not  associated  with  disease  of  the  arteries.  It  is  often 
an  attendant  upon  general  ill  nutrition,  and  worry,  and  long  hours 
of  work  and  short  hours  of  sleep. 

A  fatty  heart  sometimes  ruptures.  Now,  in  spite  of  the  care 
with  which  some  authors  have  detailed  the  physical  signs  of  this 
mishap,  we  know  nothing  positively  about  them ;  for  death  usually 
takes  place  far  too  rapidly  to  permit  of  any  such  observations.  The 
symptoms  that  are  mostly  noticed  are  these  :  the  patient  is  suddenly 
attacked  with  intolerable  anguish  in  the  heart ;  he  presses  his  hand 
to  it,  then  faints,  and  soon  expires.  Or  else  he  lives  for  a  short 
time,  suiFering  from  faintness,  cramps,  and  difficulty  of  breathing, 
and  with  death  plainly  written  on  his  face. 

Where  there  is  fatty  accumulation  on  the  heai^t,  without  fatty 
change  of  its  fibres, — a  condition  we  sometimes  find  in  persons 
whose  internal  viscera  are  loaded  with  fat, — the  manifestations  are 
those  of  a  feeble  heart,  and  different  from  fatty  degeneration  only 
in  degree.  The  first  sound  of  the  heart  is  weak  and  toneless ;  the 
pulse  is  feeble,  but,  as  Walshe  tells  us,  regular.  The  percussion 
dulness  in  the  cardiac  region  is  somewhat  increased.  A  sensation 
of  oppression  over  the  region  of  the  heart,  or  even  actual  pain,  is 
complained  of.     There  is  shortness  of  breath  on  taking  exercise. 

Atrophy  of  the  heart  is  so  rare  a  condition  that  its  symptoms 
are  scarcely  understood.  All  we  know  is  that  at  times  in  certain 
wasting  diseases,  such  as  tubercular  phthisis  and  suppurating  bone 
affections,  the  heart  atrophies ;  it  may  also  do  so  when  the  coronary 
arteries  are  calcified,  or  the  pericardium  is  tightly  adherent ;  and 
cardiac  atrophy  is  said  to  happen  occasionally  after  pregnancy 
and  chlorosis.  It  has  not  a  single  symptom  nor  a  single  sign 
by  which  it  can  be  recognized  with  certainty.  Theoretically,  the 
diminished  percussion  dulness,  clear  sounds,  and  feeble  impulse 
should  enlighten  us ;  but,  even  in  cases  w^here  there  is  no  co- 
existing fatty  change,  they  are  too  uncertain  to  be  made  a  basis  for 
diagnosis,  or  attending  lung  conditions  throw  doubt  on  several 
of  them.  There  is  great  tendency  to  palpitation,  and  the  pulse, 
Hayden  tells  us,  is  quick,  all  but  inappreciable,  yet  regular. 

28 


434  MEDICAL   DIAGNOSIS. 

Pericardial  Eflfusion. — Pericardial  effusion  alr^o  presents  the 
signs  of  a  weak  heart  with  increased  duhiess  on  percussion  in  the 
cardiac  reoiun,  and  is  verv  liable  to  be  mistaken  for  a  dilatation 
of  the  organ.  Where  the  effusion  forms  part  of  a  general  dropsy, 
the  detection  of  the  cause  of  the  latter,  in  connection  with  the  dif- 
ferent signs  which  fluid  in  the  pericardium  occasions,  will  prevent 
error.  AVhere  the  liquid  has  remained  after  an  inflammation  of 
the  membrarie,  both  signs  and  symptoms  are  like  those  of  the 
state  of  effusion  in  acute  pericarditis,  and,  although  there  are 
points  of  resemblance  to  a  dilated  heart,  there  are  also  points 
of  contrast,  as  the  subjoined  table  shows : 

Chronic  Pericarditis  with 
Dilatation  of  the  Heart.  Effusion. 

Percussion    dulness    increased   in   ex-     Percussion     dulness     increased,     but 

tent,  but  square  in  outline.  often  of  p^'ramidal  shape. 

Heart-sounds  clear  and  sharp ;   some-     Heart-sounds     feeble      and      distant- 
times,  however,  feeble.  sounding  at  the  apex,  but  distinct 

near  the  upper  part  of  the  sternum. 
No  friction  sound.  Often  friction  sound  still  heard  at  the 

base  of  the  heart. 
Dropsy  ;   signs  of  venous  stagnation  ;     Neither  dropsy  nor  venous  stagnation 
severe  cough,  and  dyspnoea.  is  observed;   or,  if  at   all,  only  in 

a  very  limited  degree.     Cough  and 
dyspnoea   are    not    such    prominent 
symptoms. 
The  history  of  the  disease  shows  it  to     The  history  frequently  points   to   the 
be  gradually  developed.  acute  attaclc. 

These,  then,  are  the  marks  of  distinction  presented  by  a  chronic 
pericardial  effusion,  a  fatty  heart,  and  cardiac  dilatation  ;  in  other 
words,  between  the  main  morbid  states  which  occasion  the  signs 
and  symptoms  of  a  feebly-acting  heart.  Before  proceeding,  let  us 
glance  at  one  more  condition,  fortunately  infrequent,  which  may 
give  rise  to  some  of  the  same  phenomena  as  those  described, — an 
accumulation  of  blood  in  the  cavities  of  the  heart.  Like  dilatation, 
this  increases  the  area  of  percussion  dulness,  and  is  often  associ- 
ated with  perverted  rhythm.  The  chief  differences,  as  far  as  our 
limited  knowledge  of  the  subject  permits  us  to  define  them,  are 
these :  the  impulse  is  generally  much  more  labored  and  irregular, 
is  sometimes  strong,  sometimes  weak,  not  so  almost  uniformly 
indistinct  or  tremulous.  There  is  much  more  venous  congestion 
of  the  face,  with  greater  dyspnoea,  and  we  often  find  some  acute 


DISEASES    OF   THE    HEART.  435 

malady,  such  as  endocarditis  or  pneumonia,  giving  rise  to  the 
cardiac  engorgement.  But  the  matter  is  often  a  very  difficult  one 
to  determine;  for  many  of  the  same  states  which  lead  to  dila- 
tation may  produce  an  accumulation  of  blood  in  the  heart ;  nay, 
dilatation  itself  predisposes  to  it. 

Diseases  of  the  Heart  exhibiting  more  or  less  of  the  Signs 
and  Symptoms  of  Enlargement  of  the  Organ,  and  accom- 
panied by  Endocardial  Murmurs. 

Valvular  Affections. — To  find  the  sounds  of  the  heart 
clearly  and  well  defined,  is  to  know  that  no  disease  of  the  valves 
exists.  When  the  valvular  apparatus  is  disordered,  the  mischief 
betrays  itself,  for  the  most  part,  by  a  blowing  sound.  If,  there- 
fore, a  murmur  of  any  permanence  be  met  with  in  the  heart,  if 
especially  it  be  associated  with  the  signs  of  either  hypertrophy  or 
dilatation,  the  inference  that  valvular  disease  exists  will  in  the 
vast  majority  of  cases  be  a  correct  inference. 

Yet  it  will  not  be  so  always  ;  for  there  are  other  morbid  states 
besides  valvular  affections  which  engender  a  murmur,  that  may 
be  even  accompanied  by  all  the  manifestations  of  enlargement  of 
the  heart.  Malformations,  such  as  communications  between  the 
auricles  or  between  the  ventricles,  or  between  the  great  vessels 
near  their  origin,  or  impoverished  blood,  or  a  misdirected  blood- 
current,  may  occasion  a  murmur. 

Now,  with  reference  to  malformations,  their  presence  in  adults, 
or  in  children  that  have  passed  the  days  of  infancy,  is  exceedingly 
rare.  The  most  trustworthy  symptom  they  present  is  that  which 
indicates  the  admixture  of  arterial  and  of  venous  blood  ;  in  other 
words,  the  symptom  of  cyanosis,  the  bluish  discoloration  of  the 
skin.  In  addition,  we  may  perceive  the  signs  of  disturbed  circu- 
lation in  the  lungs,  such  as  dyspnoea  and  cough;  and  of  irregular 
action  of  the  heart ;  and  a  blowing  sound  in  the  cardiac  region. 
Still,  the  recognition  of  these  malformations  is  always  more  or  less 
a  matter  of  conjecture.  With  the  aid  of  more  such  researches  as 
those  of  Moreton  Stille  *  and  of  Peacock,  f  we  shall  become  more 

*  Amer.  Journ.  Med.  Sci.,  Julj^,  1844. 

f  Treatise  on  Malformations  of  the  Heart ;  see  also  the  valuable  treatise  of 
Keating  and  Edwards  on  Diseases  of  the  Heart  and  Circulation  in  Infancy  and 


436  MEDICAL   DIAGNOSIS. 

accurately  acquainted  \\ith  the  pathology  of  the  different  lesions, 
and  perhaps  ultimately  be  able  to  discern  them  with  certainty 
during-  life.  At  present  it  is  in  their  rarity  that  the  safety  against 
erroi"s  of  diagnosis  lies.  A  curious  result  of  cardiac  malformation 
has  been  pointed  out, — abscess  of  the  brain  without  appreciable 
cause.* 

As  a  few  points  of  assistance,  it  may  be  mentioned  that  communi- 
cation of  the  ventricles  through  the  septum  gives  rise  to  a  systolic 
murmur  at  or  near  the  base  of  the  heart  not  propagated  into  the 
arteries ;  that  the  jjassage  of  blood  tlirough  an  open  foramen  ovale 
very  rarely  engenders  any  sound  ;  and  that,  Avhether  coexisting 
with  these  lesions  or  not,  the  majority  of  instances  of  cardiac  mal- 
formation, after  the  age  of  twelve,  present  signs  of  obstruction  at 
the  orifice  of  the  pulmonary  artery.  In  this  instance  either  a 
systolic  or  a  diastolic  murmur  may  be  there  perceived  ;  in  the 
first  case  the  second  sound  of  the  heart  is  Aveak  or  wanting  in 
the  second  interspace  on  the  left  side. 

The  resemblance  borne  by  cases  of  functional  disfurbance  of  the 
heart,  associated  with  impoverished  blood,  to  valvular  affections, 
has  already  engaged  our  attention.  The  age;  the  appearance 
of  the  patient ;  the  seat  of  the  blowing  sound  at  the  base  of  the 
heart ;  the  venous  hum  ;  the  fact  that  the  cardiac  murmur  is  fol- 
lowed by  a  sharp  second  sound, — all  are  points  upon  which  some 
stress  may  be  laid ;  yet  not  so  much  as  upon  the  absence  of  the 
phenomena  of  an  enlarged  heart.  But  if  the  question  be  asked. 
Are  the  latter  absolute  demonstrations  of  the  existence  of  an  affec- 
tion of  the  valves?  cannot  an  hypertrophied  or  dilated  heart,  Mith 
sound  valves,  be  combined  with  a  condition  of  blood  capable  of 
producing  a  murmur? — we  are  forced  to  answer  that  such  is 
possible.  Under  these  circumstances,  the  tact  of  the  physician 
mav  help  him  to  a  well-judged  decision  ;  but  the  only  proof  of  a 
well-judged  decision  is  afforded  by  time,  or  by  the  result  of  the 
treatment  which  restores  the  blood  to  its  normal  state. 

A  murmur  caused,  in  violent  excitement  of  the  heart,  by  mis- 
direction of  the  current,  due  chiefly  to  temporary  interference  with 


Adolescence,  1888  ;  and  Osier's  article  on  "  Congenital  Afl'ections  of  the  Heart, 
in  Keating's  Cyclopaedia  of  the  Diseases  of  Children. 
*  Ballet,  Archives  Generales  de  Medecine,  June,  1880. 


DISEASES   OF   THE   HEART.  437 

the  closure  of  the  valves,  or  perhaps  owing  to  altered  tension  of 
the  valves, — causes  the  exact  working  of  which  I  have  elsewhere 
inquired  into,* — may  become  a  troublesome  source  of  error  in 
diagnosis,  especially  when  heard  over  a  heart  in  a  state  of  dilated 
hypertrophy  or  of  dilatation.  Fortunately,  a  blowing  sound  of 
this  origin  and  in  this  combination  is  comparatively  rare,  and  we 
are  enabled  to  discriminate  it  from  an  organic  valvular  murmur 
by  its  not  being  persistent.  It  is  much  more  likely  to  be  heard 
at  the  apex,  or  rather,  according  to  my  own  observations,  some- 
what above  the  apex,  than  is  a  murmur  owing  to  changes  in  the 
blood  ;  and  it  diifers  from  the  systolic  blowing  sound  of  mitral 
disease  partly  by  the  peculiarity  of  seat  just  mentioned,  partly  by 
its  non-diffusion,  its  usual  absence  at  the  back  of  the  chest,  the 
want  of  harshness  in  the  inconstant  murmur,  and  the  low  pitch. 
Murmurs  of  this  kind  are  also  caused  by  obstructive  diseases  of 
the  lungs,  without  disease  of  the  heart  being  present. 

At  times  a  murmur  is  heard  which  is  not  dependent  on  a 
cardiac  affection,  but  on  lung  changes.  We  find,  for  instance,  in 
consolidation  of  the  left  apex,  especially  if  the  lung  be  also  con- 
tracted, a  murmur,  almost  invariably  systolic,  over  the  site  of  the 
pulmonary  artery  ;  or  we  may  encounter  over  large  cavities  with 
thin  walls  situated  in  the  neighborhood  of  the  heart  a  systolic, 
cardio-pulmonary  murmur,  caused,  most  likely,  by  the  agitation 
of  the  air  in  the  cavity,  the  heart  being  quite  sound. 

These,  then,  are  the  causes  which  impair  the  value  of  the  car- 
diac blowing  sound  as  a  sign  of  a  valvular  lesion.  Yet  they  do 
not  happen  often  enough  to  prevent  us  from  regarding  a  persistent 
murmur  as  eminently  indicative  of  an  organic  affection  of  the  valves. 

Let  us  suppose  that  we  are  convinced  that  the  murmur  is 
due  to  a  structural  lesion.  Can  we  say  what  its  precise  nature  is  ? 
Can  we  accurately  foretell  that  the  valve  is  merely  roughened,  or 
that  it  has  undergone  calcareous  transformation,  or  that  it  has 
been  bound  down,  or  that  it  is  lacerated,  or  that  vegetations 
spring  from  it,  or  that  its  muscular  attachments  are  sound  or 
unsound  ?  No,  assuredly  not.  The  most  we  can  do  is  to  judge 
whether  the  orifices  through  which  the  current  flows  be  narro^ved, 
or  whether,  by  the  valves  not  closing,  they  permit  of  regurgita- 


*  On  Functional  Valvular  Disorders,  Amer.  Journ.  Med.  Sci.,  July,  1869. 


438  MEDICAL   DIAGNOSIS. 

tioii  ;  and  to  distinguish  even  this  we  have  to  take  into  account 
more  tlio  time  of  the  occurrence  of  the  sound  than  its  particular 
character  or  pitch.  Indeed,  all  distinctions  based  entirely  on 
either  of  these  are  not  borne  out  by  clinical  experience.  Valves 
incompetent  to  close  the  openings  at  which  they  are  seated  may 
permit  a  murmur  to  be  generated  of  any  character  and  of  any 
pitch.  It  is  true  that  a  harsh  murmur,  like  that  of  a  saw  or  of  a 
rasp,  is  for  the  most  part  occasioned  by  a  contracted  orifice  with 
rigid  valves ;  but  many  contracted  orifices  with  rigid  valves  exist 
without  producing  such  a  rough  noise. 

A  cardiac  sound  which  is  rare,  but  Avhich,  when  present,  is 
most  generally  associated  with  a  narrowed  orifice,  is  a  distinct 
musical  tone  heard  at  the  mitral  or  aortic  valves.  It  resembles 
the  cooing  of  a  pigeon  ;  or  the  auscultator  listens  and  listens 
again,  and  directs  the  patient  again  and  again  to  suspend  the 
respiration,  before  he  becomes  convinced  that  the  sound  is  not  a 
sibilant  rale  in  the  lung.  It  is  sometimes  perceived  merely  at  the 
end  of  an  ordinary  bellows  murmur,  and  disappears  and  reappears 
from  time  to  time.  Where  this  rare  sound  is  met  with,  the  valves 
after  death  are  commonly  found  to  be  rigid  and  unyielding.  Yet 
this  is  not  always  the  case.  Sometimes  the  musical  note  is  pro- 
duced by  the  vibrations  of  clots  which  impede  the  rush  of  blood 
through  the  apertures  of  the  heart,  or  by  the  loose  edge  of  a 
valve  flapping  to  and  fro  in  the  current.  Occasionally,  too,  we 
hit  upon  it  in  chlorosis ;  but  only  very  occasionally,  and  never 
unless  it  be  then  equally  or  more  marked  in  the  arterial  system. 
We  have  the  authority  of  Stokes  for  the  observation  that  it  may 
be  suddenly  developed  and  precede  the  signs  of  structural  altera- 
tion of  the  heart.  Schroetter  maintains  that  the  musical  murmur 
is  due  to  the  vibration  of  a  fine  fibrous  band  stretched  across  the 
ventricle  or  a  valvular  orifice.* 

It  has  been  already  stated  that,  on  the  whole,  we  judge  best 
of  the  state  of  the  orifices  and  of  the  valves  by  ascertaining  the 
time  at  which  the  bellows  sound  occurs.  To  do  this  it  is,  how- 
ever, necessary  to  know  in  what  condition  the  orifices  are  during 
the  movements  of  the  healthy  heart.  Let  us  briefly  recajsitulate. 
During  the  contraction  of  the  ventricles,  the  valves  at  the  auriculo- 

*  Wien.  Med.  Blatter,  No.  1,  1883. 


DISEASES    OF    THE    HEART. 


439 


ventricular  openings  are  closed,  to  prevent  regurgitation  into  the 
auricles ;  and  the  valves  of  the  aorta  and  pulmonary  artery  are 
open,  so  as  to  permit  the  blood  to  pass  along  the  arterial  trunks. 
Durino-  the  dilatation  of  the  heart  the  reverse  takes  pla(!e  :  the 
valves  at  the  origin  of  the  great  arteries  are  shut,  to  keep  the 
blood  which  has  just  been  sent  forth  from  regurgitating,  and  those 

Fig.  37. 


Narrowing  of  the  aortic  orifice  by  vegetations  springing  from  the 
valves,  the  structure  of  which  was  indeed,  to  a  great  extent,  destroyed. 
The  engraving  illustrates  also  the  physical  signs  of  aortic  constriction. 

valves  the  function  of  which  is  to  act  as  gates  to  the  auriculo- 
ventricular  apertures  are  swung  back,  to  allow  the  stream  to  flow 
into  the  ventricles. 

If  thus  a  murmur  occur  with  the  contraction  of  the  heart  and 
the  first  sound,  it  is  owing  to  the  blood  either  regurgitating  from 
the  ventricles  into  the  auricles,  or  meeting  with  difficulty  in  passing 


440  MEDICAL    DIAGNOSIS. 

into  the  aorta  or  pulmonary  artery ;  if  it  occur  after  the  con- 
traction of  the  heart,  and  correspond  to  the  second  sound,  it  is 
due  to  the-  blood  passing  through  a  narrowed  mitral  or  tricuspid 
orifice,  or  streaming  back  into  the  ventricles  through  incompetent 
aortic  or  pulmonary  valves.  But  can  we  distinguish  at  M'hich 
valve  the  mischief  lies?  Generally  we  can.  By  attending  to 
the  site  of  greatest  intensity  of  the  murmur,  we  become  aware  of 
the  seat  of  its  production,  provided  it  be  borne  in  mind  what  are 
the  points  at  which  to  listen  to  the  different  valves.  It  is,  how- 
ever, also  necessary  to  recollect  that,  as  the  whole  heart  is  some- 
what lowered,  these  points  are  rather  below  what  they  are  in  a 
natural  state  of  things. 

Now,  we  cannot  always  say  whether  more  than  one  valve  is 
affected.  A  blowing  sound  in  the  heart,  no  matter  where  gen- 
erated, is  usually  transmitted  all  over  the  organ.  If  it  mask  the 
natural  sounds  at  other  valves,  it  is  very  difficult,  nay,  it  is  often 
impossible,  to  tell  positively  how  many  of  the  valves  are  injured, 
unless  several  spots  be  detected  at  which  the  murmur  is  intense 
and  yet  not  alike  in  character. 

Thus  the  blowing  sound  is  the  most  conspicuous  and  most  con- 
stant sign  of  a  valvular  lesion.  The  other  signs  and  symptoms 
vary  in  individual  cases.  A¥here  the  valves  are  but  slightly 
affected,  let  us  say  slightly  roughened,  as  they  sometimes  are  after 
an  attack  of  rheumatic  endocarditis,  the  heart  does  not  undergo 
any  decided  change  in  size ;  the  circulation  is  carried  on  regularly ; 
and,  in  spite  of  the  abnormal  sound  in  the  heart,  the  patient's 
health  remains  imirapaired,  or  it  is  only  occasionally  that  he  suf- 
fers from  palpitations.  An  alteration  of  the  valves  of  the  heart 
of  any  extent  produces,  however,  an  alteration  either  in  the 
capacity  of  its  cavities  or  in  the  thickness  of  its  walls,  and  the 
symptoms  of  dilatation  or  hypertrophy  make  their  appearance 
along  with  the  physical  signs  of  extended  percussion  dulness  and 
feeble  or  heaving  impulse.  Ordinarily  it  is  the  latter  we  meet 
with,  because  the  valves  of  the  left  side  are  so  very  much  more 
frequently  diseased,  and  their  derangements  lead  to  hypertrophy 
rather  than  to  dilatation.  Affections  of  the  tricuspid  valves  are 
usually  connected  with  dilatation  of  the  organ ;  hence  dropsy, 
venous  turfrescence,  and  albuminous  urine  are  in  them  more 
especially  observed ;  and  Blakiston  has  taught  us  their  frequent 


DISEASES   OF   TPIE   HEART. 


441 


association  with  engorgement  of  the  vessels  of  tlie  bi'ain,  and  liow 
this  becomes  the  predisposing  cause  of  cerebral  a[)oplcxy  when  in 
connection  with  cardiac  disease.  We  also  find  in  them,  or  rather 
in  tricuspid  insufficiency,  what  Mahot  has  more  particularly  called 
attention  to, — a  pulsation  of  the  liver  corresponding  to  each  sys- 
tole of  the  heart,  perceived  by  gently  depressing  the  abdominal 
parietes  with  the  hand   on   the  epigastrium.     In  combined  tri- 

FiG.  38. 


Insufficient  mitral  valves  permitting  regurgitation  of  the  blood.     The  position  and  time 
of  occurrence  of  the  most  significant  sign  of  the  affection  are  indicated  in  the  engraving. 

cuspid  and  mitral  narrowing  we  may  have  the  signs  of  pulmonary- 
artery  regurgitation.* 

All  valvular  lesions  may  be  combined  with  pain  in  the  prsecor- 
dia,  palpitations,  restlessness,  and  disturbed  dreams.  And  accord- 
ing as  the  deranged  circulation  through  the  heart  interferes  with 
the  circulation  in  other  parts,  special  symptoms  show  themselves 
prominently.  Thus,  we  find  those  who  labor  under  a  mitral  dis- 
ease suffering  most  from  cough,  from  dyspnoea,  and  from  attacks 
of  cardiac  asthma,  since  it  is  the  luno-  which  has  to  bear  the  brunt 


*  Dyce  Duckworth,  Clin.  Soc.  Transact.,  Jan.  1888. 


442  .MEDICAL   DIAGNOSIS. 

of  the  embarrassed  flow  of  the  bh)od.  If  we  examine  this  organ 
closely,  the  physical  sounds  afford  direct  proof  of  its  disordered 
condition.-  Here  and  there  are  heard  plentiful  moist  sounds  from 
fluid  wiiich  has  leaked  into  the  air-tubes;  here  and  there  the  re- 
spiratory murmur  is  roughened,  and  percussion  elicits  impaired 
clearness.  This  loss  of  the  natural  resonance  is  at  times  very 
manifest  at  the  upper  part  of  the  lung,  and  I  have  known  it  to 
lead  to  the  suspicion  of  tubercular  dc})()sit  in  cases  in  which  the 
autopsy  showed  the  pulmonary  tissue  to  be  healthy,  though  in  a 
state  of  extreme  congestion.  Respiratory  percussion  renders  the 
sound  again  clear.  Mitral  insufficiency  generally  leads  to  hyper- 
trophy of  the  heart ;  mitral  stenosis  not  unusually  becomes  asso- 
ciated with  dilatation. 

When  the  aortic  valves  permit  of  regurgitation,  this  gives  rise 
to  effects  which  are  perceptible  along  the  track  of  the  arteries. 
These  all  look  superficial,  and  beat  with  apparent  violence,  from 
the  force  with  which  the  thickened  left  ventricle  is  driving  the 
blood  through  the  tubes.  Yet,  when  the  finger  is  applied  to  the 
artery  at  the  wrist,  the  strength  of  the  beat  is  not  so  great  as  was 
expected.  A  short,  abrupt,  jerking  impulse  is  indeed  commu- 
nicated to  the  finger;  but  then  the  artery  immediately  recedes, 
jjroving  that  it  was  only  imperfectly  filled.  This  pulse  is  the 
only  one  which  gives  us  any  real  information  as  to  the  state  of 
the  orifices  of  the  heart ;  otherwise  the  pulse  does  not  afford  any 
very  trustworthy  indications.  In  general  terms,  it  may  be  stated 
to  be  small  and  i-ather  tense  when  the  openings  are  narrowed. 
Still,  no  stress  can  be  laid  on  this  in  a  diagnostic  point  of  view. 
The  want  of  correspondence  between  its  strength  and  the  force 
with  which  the  heart  is  acting  is  often  amazing. 

More  information  than  by  merely  feeling  the  pulse  can  be  ob- 
tained by  studying  it  with  the  sphygmograph.  But  even  with 
this,  as  thus  far  developed,  we  gather  in  valvular  diseases  rather 
corroborative  evidence  than  knowledge  which  is  not  attainable  by 
other  means  of  diagnosis.  Perhaps  with  further  research  the  in- 
strument may  be  made  available  to  inform  us  with  certainty  of  the 
degree  of  the  valvular  imperfection ;  and  this  would  be  a  great 
step  in  advance.  As  regards  the  most  distinctive  graphical  signs, 
we  obtain  them  in  aortic  regurgitation, — a  vertical  line  of  ascent 
of  great  amplitude,  a  pointed  summit,  and  a  sudden  descent,  with 


DISEASES   OF   THE   HEART. 


443 


comparatively  little  dicrotisra.  If  there  be  also  marked  aortic 
obstruction,  the  line  of  ascent  is  oblique,  or  rather  the  first  part  is 
vertical,  and  following  the  sharp  jjoint  is  a  gradual  curve-lilce  rise  ; 
if  senile  changes  in  the  artery  complicate  the  aortic  insufficiency, 
the  sharp-pointed  process  terminating  the  line  of  ascent  passes  into 


Fig 


Splijgmogiani  taken  irom  a  patient  with  aortic  insufficiency.  The  line  of 
ascent  does  not  terminate  in  as  sharp  a  point,  nor  is  the  descent  assudden,  as 
we  sometimes  find  it. 

Fig.  40. 


Sphygmogram  taken  from  a  patient  pi'esenting  tlie  sigi 


a  more  or  less  horizontal  plateau.  In  mitral  regurgitation  the 
pulse  tracing  is  usually  very  irregular ;  the  line  of  ascent  is  short 
and  unequal,  and  the  line  of  descent  disposed  to  be  oblique  and  to 
present  marked  dicrotism.  In  mitral  constriction,  it  is  claimed 
by  Mahomed*  that  the  up-stroke  is  vertical,  and  that  there  is, 
especially  after  giving  digitalis,  a  secondary  contraction  of  the 
ventricle  seen  in  the  dicrotic  wave,  which  is  very  characteristic. 

But,  instead  of  entering  into  a  detailed  description  of  the  pulse, 
however  studied,  or  of  any  separate  symptoms  of  valvular  dis- 
ease, let  us  group  them  together  with  the  physical  signs,  according 
to  the  combination  in  which  we  are  wont  to  meet  them  : 


Table  of  Valvular  Diseases. 


Sp;at  of  Murmur. 

Murmur  most  in- 
tense at  or  near 
apex  of  heart. 


Seat  of  Dis- 
ease. 


Character  of 
Disease. 


Mitral  orifice.  With  impulse, 
means  insuf- 
ficiency of 
valves,  permit- 
ting of  regnrgr- 
tafion ;  after 
impulse,  and 
running  into 
or  correspond- 
ing to  the  sec- 
ond  sound,   or, 


Correlative  Physical  Signs  and  Symp- 
toms. 

In  mitral  disease  the  heart  very  com- 
monly undergoes  dilated  hypertrophy, 
especially  the  riglit  ventricle.  The  sec- 
ond sound  of  the  pulmonary  artery, 
heard  in  the  second  left  interspace, 
is  sharp,  accentuated.  The  cardiac 
murmur  is  most  often  distinctly  jier- 
ceived  posteriorly  on  the  left  side,  near 
the  angle  of  the  scapula.  D3'spnoea 
and  dropsy  are  prominent  symptoms, 
especially  dyspnoea.     Cough  is  not  un- 


*  Medical  Times  and  Gazette,  May,  1872. 


444 


MEDICAL   DIAGNOSIS. 


Table  of  Valvular  Diseases — {Continued.) 


Seat  of  5IvRja-R. 


Skat  of  Dis- 
ease. 


Mumiur  most  in- 
tense at  or  near 
the  middle  of 
the  sternum,  or 
heard  with  equal 
distinctness  close 
to  the  sternum  in 
the  second  inter- 
spaceontheright 
side,  and  thence 
propagated  into 
the  arterial  S3's- 
tem. 


Aortic  orifice. 


Murmur  most  in- 
tense at  or  very 
near  to  the  en- 
siform  cartilage, 
and  over  the 
lower  part  of 
the  right  ven- 
tricle. 


Tricuspid  ori- 
fice. 


Character  of 
Disease. 

more  accurately 
speaking,  gen- 
erally preceding 
the  fii'St  sound, 
means  jiarroiv- 
ing  of  the  ori- 
fice. 


With  i  m  puis  e, 
means  narroiu- 
wg,  or  obstruc- 
tion ;  with  dias- 
tole, and  taking 
the  place  of  the 
second  sound, 
means  regurgi- 
tation. 


Correlative  Piiysicai, 

TOMS. 


Signs  and  Symp- 


With  impulse,  re- 
gurgitation; 
w  i  t  h  diastole, 
and  taking 
therefore  the 
place  of  the  sec- 
ond sound,  or 
preceding  the 
first,  narrow- 
ing. 


usual,  and  the  pulse  is  notuiifrequently 
found  to  bo  feeble  and  irregular.  In 
some  forms  of  mitral  narrowing,  where 
the  curtains  are  not  too  rigid,  the  mur- 
mur is  always  rough.  This  is  the  case 
usually  with  the  presystolic  murmur, 
which  is  pre-eminently  regarded  as  the 
sign  of  initial  constriction.  But  in  this 
affection  all  murmur  may  bo  absent, 
either  temporarily  or  permanently.  In 
mitral  narrowing  a  thrill  in  the  cardiac 
region  can  often  be  felt. 

Hypertrophy  of  left  ventricle.  All  the 
cardiac  sounds  may  be  normal,  except 
at  the  aortic  valve,  although  they  are 
often  somewhat  obscured  by  the  mur- 
mur. This  is  distinct  in  the  carotids, 
and  is  sometimes  as  well  heard  at  the 
ensiform  cartilage  as  over  tho  sternum, 
and  on  a  line  with  the  third  intercostal 
space, — a  fact  necessary  to  be  aware  of, 
so  as  to  avoid  confounding  the  aortic 
lesion  with  one  of  the  tricuspid  valve. 
When  the  orifice  is  constricted,  a  purr- 
ing thrill  is  frequently  observed  to 
attend  each  beat  of  the  heart.  The 
symptoms  are  often  remarkably  latent. 
There  is  very  commonly  neither  dropsy 
nor  dyspnoea.  The  pulse  is,  in  constric- 
tion, not  materially  affected  ;  in  regur- 
gitation it  is  abrupt  and  receding,  and 
all  the  superficial  arteries  and  the 
capillaries  pulsate.  It  is  not  unusual 
to  find  a  double  blowing  sound  attend- 
ing aortic  regurgitation,  probably  from 
slight  coexisting  obstruction  of  the 
orifice. 

Tricuspid  regurgitation  (for  of  tricuspid 
narrowing  our  knowledge  is  little  else 
than  theoretical)  exists  very  usually  in 
combination  with  dilatation  of  the  right 
ventricle,  and  tliei'efore  with  the  symp- 
toms of  this  condition  :  with  venous  con- 
gestions, with  dropsies,  witli  difficulty 
in  breathing.  On  account  of  the  open 
state  of  the  orifice,  tlie'  cervical  veins 
may  pulsate  during  the  movements  of 
the  heart;  and  in  all  cases  they  are  dis- 
tended. Tho  pulsatile  motion  in  the 
neck  becomes  especially  visible  when 
the  breath  is  Iwld  in  expiration.  The 
cardiac  murmur  is  ordinarily  soft,  of 
low  pitch,  is  not  transmitted  into  the 
arteries,  and  is  not  heanl  above  the  level 
of  the  third  rib.  In  some  cases  it  is  so 
feeble  as  to  be  with  difficulty  discerned. 


DISEASES   OF   THE   HEART. 


445 


Table  of  Valvular  Diseases— (Cbn/mJiecZ. 


Seat  of  Dis-     Chahactkk  of 


Seat  of  Murmur. 

OKAT  or-  uii 
EASE. 

DlSKASE. 

Murmur   most  in- 

Pulmonary 

With    impulse,    is 

tense  at  the  third 

orifice. 

n  a  r  r  0  w  i  11  y  ; 

left    costal    car- 

taking the  place 

tilage    near   the 

of  the  second 

sternum,  or  even 

sound,      regurrji- 

somewhat  lower, 

lalion. 

or  in  tl)e  second 

intercostal  space 

to  the  left  of  the 

sternum. 

CORRKLATIVK    PhYSIOAI,    SiGNS     AND    SVMP-  ' 
TOMS. 

We  have  little  knowledge,  derived  from 
clinical  ob.scrvation,  of  diseases  of  the 
pulmonary  valves,  of  all  the  valves  the 
ones  most  rarely  affected.  Nor  does  a 
murmur  in  the  situation  indicated,  and 
hardly  audible  over  the  left  apex  or 
along  the  sternum,  or  in  the  course  of 
the  great  vessels,  having  therefore  the 
characteristics  of  a  pulmonic  murmur, 
warrant  a  diaghosis  of  disease  of  the 
valves :  for  it  may  be  due  to  aijajmia ;  be 
caused  by  deposits  at  the  upper  part  of 
the  left  lung;  or  be  observed  immediately 
after  or  during  the  continuance  of  hem- 
orrhage from  the  lungs.  But  these  re- 
marks scarcely  hold  good  with  reference 
to  a  diastolic  murmur,  and  not  at  all  as 
regards  a  double  murmur.  If  this  be 
present,  and  signs  of  dilated  hypertrophy 
exist,  we  are  justified  in  concluding  the 
disease  to  be  a  lesion  of  the  pulmonary 
valves,  or  at  the  origin  of  the  artery. 
But  as  regards  the  association  with  signs 
of  hypertrophy  especially,  we  must  bear 
in  mind  that  in  rare  instances  of  mitral 
disease,  especially  regurgitation,  the  mur- 
mur is  loudest  at  the  pulmonary  area. 


In  this  manner  are  the  symptoms  and  signs  of  valvular  affec- 
tions associated.  It  is  not  exactly  the  combination  and  precisely 
the  way  in  which  they  happen  in  every  instance.  There  are  too 
many  circumstances  which  modify  them  ;  disorders  of  several 
valves  are  too  constantly  conjoined  ;  at  the  same  orifice  both  nar- 
rowing and  a  state  permitting  of  regurgitation  are  too  often  found 
to  coexist, — to  permit  any  tabular  representation  to  express  either 
all  the  symptoms  or  all  the  signs  which  may  occur  in  individual 
cases.  Apart  from  this  difficulty,  there  is  another :  even  where 
the  affection  of  a  second  valve  has  been  correctly  fixed  upon,  the 
irregularity  of  the  heart's  action  may  be  such  that  it  is  impossible 
to  say  whether  the  blowing  sound  heard  be  systolic  or  diastolic ; 
whether,  therefore,  the  orifice  be  narrowed  or  the  valves  insuffi- 
cient. But  this  is  not  a  matter  of  so  much  consequence ;  the 
matter  of  consequence  is,  to  determine  that  a  disease  of  the  valves 
is  present. 

Presuming  that  we  have  been  enabled  to  fix,  and  to  fix  accu- 


44G  MEDICAL   DIAGXOSIS. 

rately,  the  state  of  each  aperture,  there  is  a  point  where  all  our 
skill  .invariably  comes  to  a  stand-still.  AVe  cannot  tell  how  long 
it  is  possible  for  life  to  continue,  or  under  what  circumstances 
death  will  liapi)en.  It  may  take  place  suddenly  and  most  unex- 
peotedlv  in  oases  in  which  the  amount  of  disease  in  the  heart  is 
not  found  to  be  great ;  and,  on  the  other  hand,  life,  and  even  a 
tolerable  degree  of  health,  may  be  maintained  with  valves  so  rigid 
and  unyielding  that  the  point  of  the  knife  can,  at  the  autopsy, 
hardly  l)e  forced  through  them.  In  mitral  disease  the  patient 
is  liable  to  be  worn  out  by  the  dropsy  and  by  the  increasing  dif- 
ficulty of  breathing ;  and  so,  too,  in  that  still  more  serious  lesion, 
— tricuspid  regurgitation.  In  aifcctions  of  the  aortic  valves  the 
patient  suiFers  less,  but  he  is  more  liable  to  sudden  death. 

Before  dismissing  these  valvular  aifcctions,  there  are  a  few  other 
matters  which  claim  consideration,  though  the  limits  set  to  this 
work  will  prevent  their  full  discussion.  The  blowing  sound  has 
been  insisted  upon  as  the  diagnostic  sign  of  a  valvular  lesion,  and 
to  insist  upon  this  is  to  do  no  more  than  universal  experience  war- 
rants. But  there  are  undoubtedly  instances  in  which  no  murmur 
reaches  the  ear  to  show  that  the  valves  are  damaged. 

I  shall  cite  two  examples.  A  man,  thirty-five  years  of  age, 
came  under  my  care,  complaining  of  palpitation  of  the  heart,  of 
occasional  attacks  of  bronchitis,  and  of  shortness  of  breath.  His 
health  was  otherwise  good.  A  physical  examination  of  the  chest 
show^ed  the  action  of  the  heart  to  be  extremely  disturbed :  the 
impulse  was  strong,  and  the  extent  of  dulness  in  the  prsecordial 
region  increased.  A  blowing  sound  was  heard  near  the  apex,  but, 
OAving  to  the  great  irregularity  of  the  movements  of  the  heart,  it 
was  impossible  to  say  whether  it  corresponded  in  time  to  the  con- 
traction or  to  the  relaxation  of  the  organ.  The  pulse  was  small, 
frequent,  and  intermittent.  The  patient  continued  in  this  state 
for  seven  months,  the  beat  of  the  heart  becoming  more  and  more 
tumultuous ;  but  the  murmur  gradually  disappeared.  A  peculiar 
clacking  sound  took  its  place,  which  was  most  distinct  near  the 
apex,  and  was  faintly  transmitted  to  other  portions  of  the  heart. 
It  occurred  with  but  one  sound  of  the  heart, — with  which  could 
not  be  determined.  For  some  time  before  his  death  he  had  con- 
siderable cough,  with  a  frothy  expectoration  and  great  difficulty  in 
breathing.     His  face  and  hands  had  begun  to  swell.     The  imme- 


DISEASES   OF   THE   HEART.  447 

diate  cause  of  death  was  pulmonary  apoplexy.  The  heart  was 
found  in  a  state  of  dilated  hypertrophy,  and  tlie  mitral  valves 
liad  been  converted  into  a  calcareous  mass,  which  had  left  but  an 
extremely  narrow  chink  for  the  blood  to  pass  through. 

The  next  case  presents,  in  several  respects,  a  striking  similarity. 
A  gentleman,  about  fifty  years  of  age,  who  had  led  a  gay  and 
somewhat  dissipated  life,  noticed  that  he  experienced  difficulty  in 
breathing  on  the  slightest  exertion.  He  complained  also  much 
of  loss  of  appetite  and  of  distention  of  the  stomach.  I  could  not 
find  any  cause  beyond  flatulence  to  account  for  this ;  the  abdo- 
men yielded  all  over  an  extremely  tympanitic  sound.  But  to  the 
dyspnoea,  an  inquiry  into  the  state  of  the  heart  furnished  a  clue. 
The  size  of  the  organ  was  evidently  augmented,  and  its  rhythm 
very  irregular.  The  impulse  was  strong ;  but  the  sounds  were 
normal,  except  near  the  apex,  where,  taking  the  place  of  one, 
was  heard  a  dull  but  very  marked  clack.  When  the  hand  was 
applied  over  this  point,  it  felt  a  vibration  of  very  much  the  same 
character  as  that  which  the  ear  could  hear,  and,  like  this,  it  was 
limited,  or  certainly  only  distinctly  perceptible,  at  or  near  the 
apex  of  the  organ.  The  diagnosis  of  disease  of  the  mitral  valves  • 
was  made,  and  it  proved  to  be  correct.  The  dyspnoea  became 
greater  and  greater ;  the  feet,  and  subsequently  the  abdomen, 
were  distended  with  fluid ;  and  the  patient  died  with  all  the 
symptoms  of  an  unmistakable  valvular  lesion. 

My  note-book  would  furnish  me  with  many  more  such  cases  ; 
but  these  two  present  the  main  features  of  all.  All  the  instances 
of  valvular  disease  I  have  met  with,  unaccompanied  by  blowing 
sounds,  have  been  instances  of  disease  at  the  mitral  orifice,  and  of 
extreme  narrowing  of  that  orifice.  They  were  all  attended  with 
excessive  irregularity  of  the  action  of  the  lieart,  and  with  hyper- 
trophy. They  all  produced  difliculty  of  breathing.  They  all  pre- 
sented this  peculiar  clacking  sound  most  marked  near  the  apex. 
In  some,  another  sound,  more  like  that  heard  in  health,  followed 
it ;  in  others,  not.  In  some,  the  blowing  sound  gradually  disap- 
peared ;  in  others,  none  was  perceived  when  first  examined ;  and 
in  others,  again,  it  could  be  caught  occasionally,  as  a  very  short 
whifl\,  along  with  the  clacking  sound.  In  all,  the  impulse  was 
strong  and  very  variable  in  its  rhythm,  and  a  peculiar  movement 
was  felt  near  the  seat  of  the  apex, — not  the  purring  tremor  which 


448  V.  MEDICAL   DIAGNOSIS. 

SO  commonly  accompanies  the  movements  of  a  heart  the  valves  of 
which  are  damaged,  but  a  more  localized  vibration,  similar,  as  far 
as  such  similarity  can  exist,  to  the  sound  the  ear  hears. 

These  cases  are  probably  of  the  same  nature  as  those  that  are 
every  now  and  then  reported  as  valvular  lesions  in  which  the 
sounds  of  the  heart  were  normal.  I  cannot  think  that  with  a 
disease  of  the  valves  they  ever  are  so.  There  may  be  no  blow- 
ing sounds  present,  but  the  sounds  of  the  valve  affected  must  be 
different  from  what  they  are  in  health  ;  and  it  may  again,  in  all 
truth,  be  said  that  to  hear  the  natural  sounds  of  the  heart  well 
defined  is  to  bo  able  to  exclude  a  valvular  disease. 

The  other  subject  to  which  we  may  advert  is  the  possibility  of 
valves  having  been  insufficient  to  perform  their  functions  during 
life,  and  yet  no  signs  of  their  incompetence  being  detected  after 
death,  at  least  none  being  indicated  by  any  structural  change  in 
the  valves.  That  such  cases  occur,  is  attested  by  more  than  one 
observer.  In  explaining  them  we  must  take  into  account  those 
blowing  sonnds  which  are  produced  by  mere  abnormal  action  of 
the  structures  of  the  heart,  the  functional  murmurs  above  de- 
scribed, and  which  may  occur  in  hearts  of  healthy  texture  or 
in  states  of  hypertrophy  or  dilatation. 

Valvular  disease  may  be  at  times  suddenly  developed,  from 
rupture  of  a  valvulet  or  of  a  papillary  muscle  by  a  severe  strain. 
I  have  known  such  cases  to  happen  where  there  was  nothing  in 
the  history  to  lead  to  the  belief  of  previous  disease,  though  often 
there  is  some  preceding  disorganization,  such  as  a  granular  or  a 
fatty  change.  One  of  the  most  striking  diagnostic  features  is  the 
quicklv-originating  organic  murmur  attending  the  signs  of  dis- 
ordered circulation  and  cardiac  distress ;  another,  the  occurrence 
of  pain  in  the  region  of  the  heart. 

Let  me  also  briefly  here  allude  to  another  subject, — whether  the 
valvular  affection  shows  any  signs  by  which  we  can  recognize  it 
before  the  development  of  a  murmur.  We  cannot  do  so  with  any 
certaintv;  although  marked  alteration,  such  as  dulness  of  sound 
confined  to  or  most  obvious  at  a  particular  valve;  the  signs  of 
preceding  or  of  growing  hypertrophy;  and,  where  the  aortic 
valves  are  concerned,  a  distinct  accentuation  of  the  second  sound, 
while  the  first  has  become  dull  and  changed, — might  make  us 
suspect  what  is  about  to  happen. 


DISEASES    OF   THE    HEART.  449 

Displacements  of  the  Heart. 

The  heart  is  a  very  movable  organ.  Its  apex  is  tilted  upward 
by  an  enlarged  liver,  by  an  abdominal  tumor,  or  by  a  pericardial 
effusion.  It  gravitates  toward  the  median  line  when  the  walls 
of  the  heart  have  increased  in  weight  and  firmness.  But  these 
changes  are  hardly  of  a  nature  to  attract  as  much  attention  as 
finding  a  heart  beating  on  the  right  side  of  the  sternum. 

Now,  it  is  not  very  uncommon  to  meet  with  it  there  ;  and  the 
question  hnmediately  arises,  What  does  this  strange  alteration  in 
its  situation  signify,  and  how  is  it  brought  about?  It  is  usually 
produced  by  pressure  exercised  on  the  heart  by  accumulations  of 
fluid  or  of  air  in  the  left  pleural  cavity,  and  therefore  denotes, 
as  a  rule,  a  pleuritic  effusion  or  a  pneumothorax  of  the  left  side, 
and  is  accompanied  by  distention  of  that  side.  In  rarer  instances, 
the  heart  is  pushed  across  by  a  highly-distended  emphysematous 
lung ;  in  still  rarer  instances,  it  is  drawn  over  to  the  right  side 
by  a  shrinking  of  the  lung,  attended  with  dilatation  of  the  bron- 
chial tubes,  the  so-called  pulmonary  cirrhosis.  It  is  sometimes 
found  on  the  right  side,  because  it  had  been  forced  there  by  a 
pleuritic  effusion  and  had  formed  adhesions,  so  that  when  the 
fluid  was  absorbed  it  was  unable  to  return  to  its  natural  place. 
In  this  case  the  left  side  will  be  markedly  retracted,  and  not  the 
right,  as  it  is  if  cirrhosis  of  the  right  lung  be  the  cause  of  the 
abnormal  position  of  the  heart. 

The  displacement  may  further  have  been  brought  about  by  a 
cancerous  or  an  aneurismal  tumor,  or  by  any  of  the  abdominal 
viscera  having  slipped  into  the  chest  through  a  hernial  opening 
in  the  diaphragm ;  or  it  may  be  congenital.  But  these  all  are 
causes  which  seldom  exist.  Practically  speaking,  transpositions 
of  the  heart  are  met  with  in  connection  with  diseases  of  the  lungs. 
We  shall  merely  add  that  a  congenital  displacement  cannot  be 
diagnosticated  unless  all  other  causes  capable  of  producing  a  dis- 
placement have  been  proved  to  be  absent;  and  that  a  dislocated 
heart  is  able  to  perform  all  its  functions.  It  may  even  be  at- 
tacked by  acute  disease;  the  recognition  of  w^hich,*  under  such 
circumstances,  belongs  to  the  triumphs  of  physical  diagnosis. 

*  As  by  Stokes.     See  Diseases  of  the  Heart,  p.  463. 
29 


450  MEDICAL    DIAGNOSIS. 

SECTION   III. 

THORACIC   AXEUKISM. 

An  aneurism  of  the  aorta,  whether  caused  by  a  disease  of  the 
coats  of  the  artery  or  not,  whether  true  or  false,  may  affect  any 
part  of  the  vesseh  Yet  it  is  chiefly  at  the  ascending  portion  and 
at  the  arcli  that  it  is  met  with.  When  it  occurs  just  after  the 
artery  has  left  the  heart,  it  is  prone  to  elude  discovery.  Higher 
up,  nearer  to,  or  at  the  arch,  it  more  rarely  escapes  detection.  The 
tumor  manifests  itself  by  a  local  bulging,  varying  in  extent  and 
situation  according  to  the  extent  and  situation  of  the  aneurism. 
A  single  rib  alone  may  be  raised,  or  nothing  but  a  fulness  may  be 
observed.  But  some  prominent  spot  is  generally  detected,  and 
when  this  is  percussed  it  is  more  resistant,  and  returns  a  duller 
sound,  than  when  there  is  nothing  wrong  underneath.  Yet 
neither  the  bulging  nor  the  dulness  on  percussion  is  of  as  much 
significance  as  finding  a  distinct  pulsation  remote  from  the  beat 
of  the  heart.  Every  time  the  latter  is  perceived,  an  impulse  is 
communicated  to  the  fi.nger  at  the  point  in  the  chest-walls  which 
appears  to  project ;  that  is,  usually  on  the  right  side  of  the  ster- 
num in  the  second  intercostal  space,  or  in  the  same  interspace  on 
the  left  side,  or  immediately  under  the  top  of  the  bone.  Occa- 
sionally the  beat  is  double,  at  times  so  violent  as  to  shake  the 
head  of  the  listener,  and  almost  always,  unless  the  aneurism  be 
filled  with  solid  clots,  stronger  than  the  beat  of  the  heart. 

The  impulse  may  be  accompanied  by  a  distinct  thrill.  But 
this  is  not  always  present,  and,  when  present,  is  not  always  con- 
stant ;  since  it  may  disappear  and  reappear.  It  is  thus  a  serious 
mistake  to  regard  the  thrill  as  the  requisite  sign  of  an  aneurismal 
enlargement ;  yet  there  is  no  mistake  more  common,  except,  per- 
haps, one, — to  consider  that  the  motion  of  the  blood  in  the  sac 
must  necessarily  engender  a  murmur.  The  ear,  applied  over  the 
prominence,  hears  often  nothing  that  in  the  least  resembles  a 
murmur,  but  sounds  like  those  of  the  heart,  sometimes  two,  the 
fiirst  weighty  and  prolonged ;  sometimes  but  one,  and  that  one 
longer  and  more  intense  than  the  corresponding  first  sound  over 
the  ventricles. 


THOKACIC   ANEURISM.  451 

Thus,  then,  neither  thrill  nor  murmur  is  essential  to  the  diag- 
nosis of  an  aneurism.  What  is  much  more  essential,  is  to  find 
two  points  of  pulsation  in  the  chest, —  two  hearts,  apparently, 
each  with  its  own  distinct  beat,  its  own  distinct  sounds. 

An  aneurismal  tumor  in  the  chest  gives  rise  to  symptoms  which 
vary  somewhat  according  to  its  seat  and  extent.  Prominent  among 
them  stand  those  occasioned  by  pressure.  The  sac  presses  on  the 
adjacent  kir-tubes,  and  shortness  of  breathing,  or  peculiar  cough 
and  signs  counterfeiting  those  of  a  chronic  laryngeal  disease,  are 
the  result ;  or  it  presses  on  the  oesophagus,  and  the  patient  suffers 
from  difficulty  in  swallowing;  or  it  presses  on  the  subclavian  ar- 
tery, and  the  pulses  at  the  two  wrists  are  noticed  to  be  strikingly 
different;  or  on  the  carotid,  and  pain  in  the  head,  dulness  of  mind, 
occasional  giddiness,  and  flashes  of  light  before  the  eyes,  are  com- 
plained of;  or  on  the  venous  trunks,  and  the  superficial  veins  of 
the  neck  and  thorax  are  seen  to  be  engorged,  and  the  skin  becomes 
very  puffy  and  swollen ;  or  on  the  trunk  of  the  sympathetic  nerve 
or  on  its  ganglia  and  their  communications,  and  marked  contrac- 
tion, or,  in  rare  instances,  dilatation,  of  the  pupil  of  the  eye  on  the 
side  of  the  aneurismal  swelling,  is  perceived,  or  profuse  sweating 
becomes  an  annoying  complication.  All  these  signs,  then,  dejiote 
pressure,  and  pressure  connected  with  a  pulsating  tumor  in  the 
chest  means  an  aneurism. 

I  say  with  a  pulsating  tumor,  because  a  cancerous  or  other  in- 
tra-thoracic  morbid  growth  may  produce  exactly  the  same  signs  of 
compression  as  an  aneurismal  tumor, — the  same  stridor,  the  same 
cough,  the  same  feebleness  of  respiration  in  one  lung  from  partial 
obliteration  of  its  bronchial  tube.  But  the  solid  tumor,  large 
though  it  be,  does  not  pulsate,  or,  if  it  do,  pulsates  but  very 
feebly,  and  not  with  the  heaving  motion  of  a  distending  aneu- 
rismal sac.  The  tumor,  which  for  the  most  part  has  its  seat  in 
the  mediastinum,  renders  a  large  surface  dull  on  percussion,  and 
communicates  a  much  greater  feeling  of  resistance  to  the  percuss- 
ing finger.  Yet  the  ear  listens  in  vain  over  the  prominence  for 
the  weighty  sound  with  each  beat  of  the  heart,  or  for  the  hoarse 
murmur  of  the  blood  streaming  through  the  sac.  It  is  only  where 
a  solid  growth  presses  on  the  artery  that  any  murmur  is  per- 
ceived ;  and  this  is  different  from  the  superficial  loud  sounds  or 
murmurs  of  an  aneurism.     Further,  a  tumor  is  not  confined  to 


452  MEDICAL   DIAGNOSIS. 

the  course  of  the  aorta ;  it  is  more  commonly  connected  with  a 
distended  state  of  the  veins  of  the  neek  and  thorax,  and  with 
anlenia  (if  the  arm  and  chest ;  the  pain  it  occasions  is  often  more 
continued,  and  less  neuralgic  in  its  nature.  IMoreover,  as  most  tho- 
racic tumors  arc  cancerous,  the  violent  constitutional  disturl)ancej 
the  formation  of  external  swellings,  and  the  peculiar  cun-ant-jelly 
expectoration,  aid  us  in  arriving  at  a  correct  conclusion.  Sarcoma, 
lymphomata  and  lymphadenoraata  of  the  mediastinum  come  next 
in  frequency  to  cancer.*  They  all  tend  to  grow  inward  rather 
than  outward,  and  affect  the  anterior  mediastinum  far  oftener 
than  the  other  two  spaces. 

As  regards  abscess  of  the  mediastinum,  we  do  not  find  the 
pressure  signs  generally  so  marked  as  in  aneurism,  and  we  may 
be  able  to  detect  fluctuation  at  the  edge  of  the  st-ernum  or  at  the 
supra-sternal  notch.  The  pain  is  usually  very  great ;  the  eleva- 
tion of  temperature  is  significant.  The  sounds  over  the  mass  are 
not  those  of  an  aneurismal  sac;  there  are  certainly  no  distinctive 
murmurs,  and  we  find  no  marked  expansile  pulsation.  This 
absence  of  distinct  pulsation  was  the  main  point  of  dissimilarity 
between  an  aneurism  and  an  abscess  of  the  mediastinum  some 
time  since  under  my  care,  which,  after  lasting  a  year,  and  simu- 
lating aneurism  most  closely  in  the  pain,  the  dulness  on  percus- 
sion, the  difficulty  of  breathing  and  of  swallowing,  and  the  altered 
voice, — having,  therefore,  pressure  signs  much  more  marked  than 
usual, — got  well  by  breaking  internally  and  by  the  discharge,  as 
expectoration,  of  large  amounts  of  purulent  matter. 

The  obvious  inequality  of  the  pupils,  which  is  found  in  a  certain 
number  of  cases  among  the  signs  of  an  aneurism,  is  of  little  aid. 
in  a  differential  diagnosis  from  intra-thoracic  tumor,  for  a  thoracic 
cancer  has  been  noted  to  occasion  the  same.f  The  rarity  of  a  non- 
aneurismal  tumor  in  the  chest  is,  however,  very  great;  and,  prac- 
tically speaking,  when  the  signs  of  an  intra-thoracic  tumor  are 
met  with  we  shall  be  generally  correct  in  thinking  that  it  is  an 
aneurism  we  have  to  treat,  even  should  the  pulsations  not  be  very 
obvious. 


*  Hare,  Mediastinal  Disease,  1889. 

t  MacDonnell,  Montreal  Medical  Chronicle,  June,  1858;  Gairdner,  Clinical 
Medicine,  and  Ogle,  Medico-Chirurgical  Transactions,  vol.  xli. 


THORACIC   ANEURISM,  453 

Let  lis  suppose  that  we  are  satisfied,  owing  to  a  marked  impulse, 
that  we  have  not  a  solid  growth  or  an  abscess  to  deal  with, — does 
a  pulsation  uniformly  denote  an  aneurism?  Can  we  say,  on  ac- 
count of  the  impulse,  that  it  is  an  aneurismal  enlargement?  If 
there  be  also  swelling  and  signs  of  pressure,  we  can ;  should 
these  not  exist,  we  cannot  be  so  sure.  For  a  pulsation  in  the 
chest  not  immediately  over  the  region  of  the  heart,  although  it  is 
nearly  always  indicative  of  an  aneurism,  may  be  owing  to  other 
causes.  Where  the  aortic  valves  are  insufficient,  there  may  be 
a  pulsation  in  the  aorta;  an  empyema  may  pulsate;  a  dilated 
auricle  may  occasion  an  impulse  separate  from  that  of  the  ven- 
tricles; a  pulmonary  artery  surrounded  by  consolidated  lung  may 
distinctly  exhibit  its  beat.  In  all  of  these  the  signs  of  pressure 
on  the  surrounding  parts  are  wanting;  and,  on  the  other  hand, 
they  show  phenomena  which  an  aneurism  lacks. 

Insufficient  aortic  valves  are  accompanied  by  hypertrophy  of  the 
left  ventricle.  So  is  at  times  a  thoracic  aneurism ;  but,  instead 
of  the  throbbing  at  the  upper  anterior  part  of  the  chest  being 
attended,  as  in  aneurismal  swelling,  with  a  natural  or  wdth  an  un- 
equal beat  at  i\\e  wrist,  there,  as  well  as  in  the  larger  trunks  in 
the  neck  and  arms,  is  perceived  that  strong  and  peculiar  pulsation 
which  is  so  characteristic  of  inadequate  aortic  valves.  Then, 
again,  a  murmur  is  much  more  common  in  this  aifection  of  the 
valves  than  it  is  in  aortic  aneurism  ;  and  is  usually  a  loud  double 
murmur,  most  distinct  at  the  right  base  of  the  heart,  and  associated 
with  a  double  murmur  in  the  femorals  made  evident  by  pressure 
with  the  stethoscope.  This  is  very  rare  in  aneurism  of  the  aorta; 
moreover,  the  murmur  heard  over  an  aneurismal  pulsation  is  better 
marked  over  its  seat  than  over  the  heart,  and  is  mostly  single, 
systolic  and  short,  hoarse  and  of  low  pitch.  In  truth,  it  differs  in 
distinctness  as  well  as  in  quality  from  the  murmur  discerned  at  the 
base  of  the  heart,  which  may  be  transmitted  from  the  aneurism,  or 
may  depend  upon  coexisting  cardiac  disease.  Then  the  sphygmo- 
graphic  tracings  may  also  be  of  some  value.  Those  of  aortic  regur- 
gitation, as  above  described,  are  for  the  most  part  characteristic ; 
while  an  oblique  line  of  ascent,,  a  loss  of  the  summit  wave,  and  a 
modification  of  the  dicrotism  are  usual  when  an  aneurism  is  seated 
on  a  main  trunk  after  its  origin  from  the  aorta.  While  alluding 
to  the  diagnosis  of  aortic  valve  disease,  I  may  mention  coarctation 


454  MEDICAL   DIAGNOSIS. 

or  constriction  of  the  aorta,  whk-li  in  vciy  rare  cases  is  associated 
with  the  valvular  afTeetion.  It  oenerally  happens  just  at  or  below 
the  insertion  oi'  the  ductus  arteriosus,  and  furnishes  as  its  only 
special  signs  a  dilatation  of  certain  collateral  vessels  at  the  upper 
part  of  the  thorax,  and  diminished  size  and'  feel)le,  retarded  pul- 
sation of  the  femorals.  The  arteries  of  the  head  and  neck,  as 
well  as  the  epigastric  and  mammary  arteries,  throb,  and  there  may 
be  a  marked  thrill  at  the  upper  part  of  the  chest  near  the  sternum, 
and  a  murmur  there  louder  than  over  the  heart ;  pressure  signs 
are  absent,  and  the  dilated  vessels  are  often  the  seat  of  a  purring 
noise.* 

A  pulsating  empyema  is  seldom  met  with ;  yet  a  collection  of 
fluid  in  the  cavity  of  the  chest  may  vibrate  with  the  motion  of  the 
heart,  and  throb  with  such  distinctness  as  closely  to  simulate  an 
aneurism.  To  determine  the  real  nature  of  the  pulsation  in  these 
cases,  we  must  attach  importance  to  the  situation  of  tlie  expand- 
ing mass,  which  is  not  often  that  of  an  aneurism,  and  to  the  signs 
which  point  out  that  liquid  has  accumulated  within  the  pleural 
sac.  We  also  note  the  circumstance  that  over  the  seat  of  impulse 
there  are  no  peculiarly  marked  sounds,  no  murmurs,  no  thrill ; 
moreover,  the  beat  is  not  apt  to  be  as  strong  as  that  of  the 
heart,  which  is  displaced.  The  pulsation  may  happen  both  in 
acute  and  in  chronic  pleurisy,  and  be  associated,  as  in  Osier's f 
case,  with  persistent  tenderness  of  the  thoracic  walls.  There  may 
be  a  number  of  these  pulsating  tumors.J  Pulsating  pleurisies  are 
nearly  always  left-sided  and  purulent ;  there  is  generally  latent 
pneumothorax  present.§ 

A  dilated  auricle,  the  walls  of  which  are  at  the  same  time 
hypertrophied,  may  give  rise  to  a  movement  separate  from  that 
of  the  beat  of  the  ventricle.  Bouillaud  cites  an  example  of  this 
nature,  in  which  a  doable  motion  was  perceptible  in  the  second 
intercostal  space  of  the  left  side,  in  a  person  whose  heart  was 

*  For  cases  of  coarctation  of  the  aorta,  see  Peacock,  Brit,  and  For.  Med.- 
Cliir.  Kev.,  April,  1860;  Walshe,  Med.  Times  and  Gaz.,  Oct.  1857;  Meigs, 
Amer.  Journ.  Med.  Sci.,  Jan.  1869  ;  Lebert,  in  Virchow's  Handbuch  ;  Quincke, 
in  Ziemssen's  Cycloptedia;  E.  H.  Babcock,  N.  Am.  Pract.,  Chicago,  1889,  i. 

t  Amer.  Journ.  Med.  Sci.,  Jan.  1889. 

j  Henry,  Proc.  Phila.  Co.  Med.  Soc,  vol.  iii. 

§  Comby,  Arch.  Gen.  de  Med.,  April,  1889. 


THORACIC   ANEURISM.  455 

extensively  hypertrophiecl  and  whose  mitral  valves  were  indu- 
rated. Such  cases  are  extremely  rare.  The  signs  of  an  accom- 
panying valvular  affection  and  of  enlargement  of  the  ventricles, 
and  the  probable  presence  of  dropsy,  would  serve  to  distinguish 
a  dilated  anricle  from  aneurism  of  the  arch.  And  this  is  the 
only  form  of  enlargement  of  the  heart  which  is  at  all  likely  to  be 
mistaken  for  an  aneurism.  In  cases  of  hypertrophy  or  dilatation 
as  we  ordinarily  meet  with  them,  there  is  but  one  motion  dis- 
cernible,— that  over  the  ventricles, — and  not  two  beats  at  some 
distance  from  each  other ;  the  signs  of  pressure,  too,  are  wanting. 
A  pulmonary  artery  surrounded  by  consolidated  lung-tissue  may 
cause — especially  if  the  vessel  be  somewhat  widened — a  distinct 
pulsation.  But  the  seat  of  the  dulness  near  the  apex  of  the  left 
lung ;  its  non-extension  over  the  median  line ;  the  limitation  of 
the  murmur  to  the  site  of  the  pulmonary  artery,  or,  in  some  in- 
stances, to  this  vessel  and  the  subclavian ;  the  sharply-defined 
second  sound  of  the  pulmonary  artery  in  the  second  interspace 
on  the  left  side ;  the  symptoms  and  physical  signs  of  phthisis,  the 
most  common  cause  of  the  consolidation,  and  a  morbid  condition 
which  of  itself  would  appear  to  exclude  an  aneurism ;  the  absence 
of  pa;in  and  of  the  phenomena  caused  by  pressure, — all  these 
prove  the  murmur  and  the  pulsation  not  to  be  due  to  an  aortic 
aneurism.  Absence  of  pain  and  of  pressure  signs,  and  accen- 
tuation of  the  second  sound,  are  also  the  chief  signs  by  which 
we  distinguish  those  comparatively  rare  cases  of  murmur  in  the 
second  interspace,  close  to  the  left  of  the  sternum,  which  are  due 
to  retraction  of  the  lung  and  uncovering  of  the  heart  and  pulmo- 
nary artery.  The  murmur,  which  has  been  specially  studied  by 
Quincke  *  and  Balfour,t  is  systolic  and  loud,  and  mostly  disap- 
pears on  deep  inspiration.  The  pulsation  is  marked,  though  not 
so  strong  as  that  of  the  heart ;  the  singular  murmur  is  supposed 
to  be  owing  to  compression  of  the  pulmonary  artery  by  the  heart 
during  the  systole.  In  many  respects  it  is  like  the  murmur  heard 
over  the  pulmonary  artery  in  certain  lung  affections,  which  I  have 
elsewhere  investigated.^ 


*  Berliner  Klinische  Woehenschrift,  1870. 

t  Lectures  on  Diseases  of  the  Heart,  Loudon,  1876. 

t  Amer.  Journ.  Med.  Sci.,  Jan.  1859. 


45(5  MEDICAL  DIAGNOSIS. 

Another  abnormal  condition  which  may  be  mistaken  for  an 
anenrism  is  a  malj'onnation  of  the  clicd,  particnlarly  when  pro- 
duced by  great  prominence  of  the  upper  part  of  the  sternum. 
This  error  is  more  especially  apt  to  occur  if  there  be  coexist- 
ing disturbance  of  the  heart,  whether  of  functional  or  of  organic 
origin.  I  have  seen  cases  Avhere  the  beating  of  the  arteries  of  the 
neck,  accompanied  by  an  enlargement  of  the  thyroid  gland  and 
by  cardiac  palpitatiou,  was  believed  to  be  an  aneurism,  mainly 
because  it  was  combined  Avitli  very  decided  prominence  of  the 
upper  portion  of  the  sternum.  But  tliere  were  no  distinctly 
localized  tumefaction  and  pulsation,  no  altered  sounds,  no  signs 
of  pressure.  I  have  also  met  with  instances  in  which  the  active 
pulsation  of  the  thyroid  gland,  both  in  exophthalmic  and  in  ordi- 
nary goitre,  gave  rise  to  the  idea  of  an  aneurism,  but  in  which  no 
change  of  the  chest-^\•alls  existed.  In  such  cases  the  carotids  and 
radials  beat  equally ;  a  blowing  murmur,  attended  by  a  contin- 
uous hum,  is  heard — certainly  in  instances  of  exophthalmic  goitre 
— over  the  enlarged  gland ;  there  is  nowhere  a  point  of  localized 
pulsation,  and  there  are  also  no  signs  of  pressure. 

3IaIposition  of  the  aorta,  due  to  rickets,  may  simulate  an  aneu- 
rism closely.  Balfour*  has  pointed  out  how  misleading  may  be 
the  abnormal  pulsation  with  the  dulness  on  percussion,  and  the 
right-sided  prominence  of  the  chest.  Moreover,  thrill,  murmurs 
loudest  over  the  pulsating  mass,  and  cardiac  hypertrophy,  may 
coexist.  AVe  must  be  guided  in  our  opinion  by  the  history  of  the 
case  ;  by  the  distortion  of  the  spine ;  by  the  extended  superficial 
dulness  on  percussion,  out  of  proportion  to  the  extent  and  strength 
of  the  pulsation  of  the  tumor,  which  is  less  forcible  than  that  of 
the  heart ;  by  the  displaced  position  of  the  heart,  which  is  tilted 
upward  and  thrown  over  more  to  the  right;  and  especially  by  the 
absence  of  any  signs  of  pressure. 

The  signs  of  pressure  play,  then,  a  very  important  part  in  the 
diagnosis  of  an  aneurism.  They  are  rarely  absent,  although  they 
do  not  always  manifest  themselves  in  the  same  manner :  some- 
times it  is  bone,  sometimes  lung,  sometimes  oesophagus,  sometimes 
nerve-fibre,  which  bears  the  brunt  of  the  distending  swelling. 
These  signs  of  pressure  are  wanting  if  the  sac  be  very  small  or 

*  Diseases  of  the  Heart,  London,  1876. 


THORACIC   ANEURISM.  457 

be  absent ;  or  not  prominent  if  the  artery  be  simply  dilated,  in 
which  case  nothing  but  a  constantly  pulsating  tumor  can  be  de- 
tected. At  times  evidences  of  compression  may  be  recognized 
by  the  attentive  physician  when  no  throbbing  swelling  can  be 
discerned ;  and  from  them  he  infers  the  true  nature  of  the  case, 
although  utterly  unable  to  discover  any  of  the  ordinary  physical 
signs  of  an  aneurism.  Whenever,  indeed,  obstinate  and  anom- 
alous thoracic  symptoms,  which  might  be  explained  by  the  pres- 
ence of  an  aneurismal  sac,  occur  in  a  person  whose  lungs  and 
heart  appear  to  be  in  every  respect  sound  and  whose  general 
health  is  not  materially  affected,  we  may  suspect  an  aneurism  to 
be  the  source  of  the  disorder.  So,  too,  if  any  laryngeal  affection, 
or  if  any  difficulty  in  swallowing,  exhibit  rather  peculiar  symp- 
toms. It  is,  in  truth,  imperative  in  all  cases  of  chronic  disease 
of  the  larynx,  or  where  there  are  indications  of  a  stricture  of  the 
oesophagus,  to  examine  the  chest  carefully,  so  as  to  avoid  the  grave 
error  of  overlooking  what  may  be  the  only  cause  of  the  w^hole 
disturbance. 

The  symptoms  of  chronic  laryngitis  especially  are  at  times  most 
astonishingly  simulated,  and  it  may  happen  that  the  patient,  trust- 
ing to  his  feelings,  refers  obstinately  to  the  chest  as  the  seat  of  the 
disorder,  while  the  physician  as  obstinately  sees  nothing  but  the 
presumed  aifection  of  the  larynx.  Even  if  we  cannot  discern 
any  pulsation,  the  following  signs  may  furnish  a  key  to  the  case. 
There  is,  as  in  chronic  laryngeal  disease,  alteration  of  the  voice, 
with  stridor,  and  peculiar  cough ;  but  the  voice  is  not  so  uni- 
formly changed.  Often  it  retains  much  of  its  natural  character ; 
and  the  loss  is  not  so  progressive,  and  the  aphonia  not  so  perma- 
nent. Hoarse  the  voice  may  be,  but,  as  the  direction  of  the  press- 
ure varies,  it  alters  rapidly  both  in  pitch  and  in  power.  The 
cough  is  most  commonly  loud  and  paroxysmal,  and  has  a  ring- 
ing sound.  Dyspnoea  is  a  very  constant  symptom,  and  is  often 
attended  with  wheezing  or  stridulous  breathing,  which  is  not  per- 
sistent, and  is  sometimes  only  produced  after  a  deep  inspiration. 
The  stridor,  however,  as  Stokes  points  out,  differs  from  that  of  an 
obstructive  disease  of  the  larynx  by  its  seeming  to  issue  from  the 
notch  at  the  sternum,  and  not  from  above,  from  the  larynx  itself. 
If,  in  addition,  the  respiration  be  found  to  be  markedly  unequal 
in  the  two  lungs,  the  diagnosis  of  aneurism  may  be  ventured 


458  MEDICAL    DIAGNOSIS. 

upon ;  aiifl  it  will  l)c  confirmcfl  by  finding  no  change  in  the 
larynx,  when  examined  with  the  huyngoscope,  sufficient  to  account 
for  the  laryngeal  symptoms,  or  such  a  change — paralysis  of  only 
one  cord,  for  instance — as  could  be  readily  explained  by  pressure 
on  one  recurrent  nerve.*  Of  course,  the  detection  of  dulness  on 
percussion,  of  sounds  stronger  than  or  otherwise  different  from 
those  in  the  cardiac  region,  or  the  occurrence  of  a  hemorrhage, 
would  place  the  diagnosis  beyond  doubt. 

In  some  cases  of  aneurism,  pain  is  among  the  earliest  sym2)toms, 
and  tlie  patient  complains  much  of  it  before  there  is  a  single  phys- 
ical sign  indicative  of  the  presence  of  a  tumor.  The  pain  is  de- 
pendent upon  pressure  on  the  nervous  filaments :  it  may  shoot 
toward  the  shoulder  or  the  neck,  along  the  arm,  or  deep  into  the 
centre  of  the  chest.  Dull,  deep  pain,  boring  and  constant,  occurs 
when  the  pressure  of  the  sac  is  leading  to  absorption  of  the  ver- 
tebra. Over  the  seat  of  the  swelling  there  is  often  pain,  asso- 
ciated with  great  tenderness. 

The  severity  of  the  pain  may  give  rise  to  emaciation  and  ex- 
haustion, and  become  a  cause  of  death  ;  but  death  does  not  often 
take  place  from  exhaustion.  More  usually  the  patient's  life  is  cut 
short  by  the  aneurism  bursting,  either  externally  or  into  internal 
parts, — into  the  trachea,  bronchial  tubes,  oesophagus,  pericardium, 
pleura,  pulmonary  artery,  or  spinal  canal.  Yet  it  is  not  always 
the  first  rent  which  leads  to  the  fatal  issue ;  this,  as  we  learn  from 
the  cases  that  ^yebbt  has  analyzed,  may,  when  the  aneurism 
breaks  externally,  not  happen  for  weeks  after  the  accident. 

Now,  can  w^e  foretell  the  course  of  an  aneurism,  and  the  prob- 
able mode  of  death  it  is  likely  to  occasion  ?  We  cannot ;  for  in 
order  to  do  so  it  would  be  requisite  to  determine  accurately  its 
seat,  so  as  to  kno^\'  what  tissues  are  likely  to  be  encroached  upon. 

*  The  aphonia  in  aneurism  is,  indeed,  attrihutahle  to  pressure  on  the  re- 
current laryngeal  nerve ;  and,  as  mentioned  by  Tufnell,  a  stridulous  voice, 
unaccompanied  by  aphonia  and  dysphagia,  tends  to  show  that  the  tumor  is 
on  the  right  side  of  the  trachea  and  does  not  affect  the  oesophagus  or  the 
recurrent  larvngeal  nerve.  When  the  aneurism  presses  on  the  trachea  at  its 
bifurcation,  the  voice  will  be  raucous.  In  a  case  of  aortic  aneurism  recorded 
by  Habershon  (Med.-Chirurg.  Transact.,  1865),  the  aneurism  implicated  the 
left  recurrent  laryngeal  uerve,  and  there  was  atrophy  of  the  muscles  of  the 
larynx,  as  well  as  left-sided  pneumonia. 

t  Amer.  Journ.  Med.  Sci.,  Oct.  1874. 


THOUACrC    ANEURISM.  459 

And  this  is  veiy  difficult,  nay,  often  impossible.  It  is  true  that, 
when  the  swelling  gives  rise  to  phenomena  like  those  of  angina 
pectoris,  we  may  surmise  it  to  be  in  the  ascending  portion  of  the 
aorta  and  near  the  cardiac  plexus  of  nerves,  and  look  for  its 
breaking  into  the  pericardium  or  the  pulmonary  artery ;  when  it 
is  accompanied  by  laryngeal  stridor  or  other  laryngeal  symptoms, 
it  probably  involves  the  posterior  and  lower  portions  of  the  arch, 
and  will  cause  death  by  strangulation  or  by  exhaustion ;  when  it 
produces  much  dyspnoea,  it  is  apt  to  be  seated  in  the  descending 
part  of  the  arch,  and  death  may  take  place  by  the  aneurism 
bursting  into  a  bronchial  tube,  or  by  pneumonia.  But  in  regard 
to  all  these  matters  we  can  usually  do  little  else  than  conjecture ; 
because  a  tumor  within  the  chest  leads  to  such  displacements  that 
its  relations  to  the  surrounding  structures  cannot  be  clearly  ascer- 
tained during  life.  The  most  valuable  information  we  obtain  is 
from  a  study  of  the  physiological  changes, — from  the  symptoms, 
therefore,  of  disturbed  function. 

An  aneurism  of  the  descending  aorta,  between  the  arch  and 
the  diaphragm,  produces,  if  extensive,  dulness  on  percussion  and 
bulging  posteriorly,  and  may  exhibit  the  same  physical  signs  and 
symptoms  as  an  aneurism  in  the  neighborhood  of  the  arch.  A 
gnawing  sensation  in  the  vertebrae  has  been  especially  noticed. 
Yet,  in  spite  of  the  most  careful  scrutiny,  an  aneurism  of  the 
descending  aorta  often  escapes  detection,  or  its  physical  signs, 
as  a  case  recorded  by  Walshe  *  proves,  may  exist  to  the  right  in- 
stead of  to  the  left  of  the  spinal  column,  because  the  vessel  has 
been  dragged  across  the  median  line  by  its  enlargement. 

An  aneurism  of  the  heart  may  in  exceptional  instances  produce 
localized  bulging  in  the  cardiac  region.  But,  whether  it  does  so 
or  not,  it  is  beyond  the  reach  of  positive  diagnosis.  We  may 
suspect  it  if  the  bulging  have  been  preceded  by  signs  of  fibroid 
degeneration  of  the  walls  of  the  heart. 

In  rare  instances  we  find  a  varicose  aneurism  communicating 
with  either  the  ascending  or  the  descending  vena  cava.  These 
aneurisms  mostly  present  the  ordinary  signs  of  a  thoracic  aneu- 
rism ;  but,  in  addition,  great  venous  enlargement  above  the  dia- 
phragm, with  oedema  of  the  face  and  hands  and  arms ;  a  purple 

"  Diseases  of  the  Heart. 


460  MEDICAL   DIAGNOSIS. 

hue  of  the  face  and  the  upper  part  of  the  IhhIv,  and  spots  of 
eeehyniosis  in  the  skin  ;  a  jerking-  pulse  ;  a  purring  thrill ;  and 
a  whirring  systolic  murmur,*  ditfuscd  all  over  the  front  of  the 
chest.  The  oedema  and  the  symptoms  of  venous  disturbance 
come  on  suddenly.  In  instances  of  occlusion  of  the  vena  cava 
the  great  venous  distention  is  not  accompanied  by  the  physical 
signs  of  an  aneurism,  nor  by  the  thrill,  nor  by  the  cyanosis  and 
oodematous  swelling.f 

Let  us,  in  conclusion,  glance  at  the  other  kinds  of  aneurism 
■within  the  thorax, — that  of  the  innominate  and  that  of  the  pul- 
monary artery. 

An  aneurism  of  the  imiomrnate  artery  is  strictly  limited  to  the 
right  side  of  the  body.  It  diifers  from  that  of  the  arch  by  the 
higher  situation  of  the  pulsating  swelling;  by  the  displacement  of 
the  clavicle  ;  by  the  comparative  absence  of  signs  of  pressure  on 
the  larynx  and  oesophagus ;  and  by  the  fact  that  compression  of 
the  right  subclavian  and  carotid  diminishes  the  beat  of  the  tumor, 
while  it  exerts  no  effect  on  an  aortic  aneurism.  Such  are,  at  all 
events,  the  marks  of  distinction  indicated  by  the  observations  in 
Holland's  J  excellent  memoir.  An  additional  sign  is  mentioned  by 
Wardrop.§  It  is  that  when  the  innominate  is  aifected  the  diffi- 
culty will  appear  first  on  the  tracheal  side  of  the  sterno-niastoid  ; 
but  on  the  cervical  side  if  the  aneurism  be  of  the  subclavian. 

An  aneurism  of  the  pulmonary  artery  is  a  rare  disease.  Its 
main  phenomena  are  :  a  strongly  pulsating  swelling,  perceptible 
to  the  left  of  the  sternum,  and  limited  to  the  second  intercostal 
space  near  the  costal  cartilages ;  a  marked  thrill  with  each  expan- 
sion of  the  aneurism  ;  and  in  some  instances  a  rough  nuirmur, 
Avhich  is  not  discovered  at  the  notch  of  the  sternum  or  above  the 
clavicles ;  lividity  of  the  face ;  dropsy ;  and  great  difficulty  of 
breathing.  1 1     The  most  significant  points  of  difference  between  an 


*As  in  Mayne's  case,  Dublin  Quart.  Journ.  of  Med.  Sci.,  Nov.  1853;  also 
in  Glascow's  case,  St.  Louis  Courier  of  Med.,  Jan.  1885. 

t  Arthur  V.  Meigs's  case,  Transact.  Coll.  of  Phys.  of  Phila.,  1886. 

X  Dublin  Quarterly  Journal,  vol.  xii. 

§  Holmes's  Surgery,  vol.  iii.  p.  562. 

II  In  the  case  detailed  by  Skoda,  Auscultation  and  Percussion,  the  dropsy 
was  very  great,  and  the  face  cyanotic ;  there  Avas  a  faint  murmur  over  the 
base  of  the  heart,  but  none  over  the  pulmonary  artery. 


THORACIC   ANEURISM.  461 

aneurism  of  the  pulmonary  artery  and  an  aneurism  of  tlie  atjrta 
consist  in  the  symptoms  just  mentioned,  and  in  the  absence  of 
obvious  evidences  of  pressure.  The  situation,  too,  of  tlie  physical 
phenomena  is  important ;  yet  we  must  bear  in  mind  that  an 
aneurism  of  the  arch  may  occasion  a  pulsating  tumor,  mainly  to 
the  left  of  the  sternum,  and  may  even  break  into  the  pulmonary 
artery.  A  mere  distinct  beating  of-  the  pulmonary  artery  is  dis- 
crimhiated  from  an  aneurism  of  this  vessel  by  the  non-existence  of 
a  palpable  swelling,  of  drojDsy,  of  greatly-embarrassed  breathing, 
of  lividity  of  the  face,  and  by  the^usually  coexisting  signs  of  some 
consolidation  of  the  left  lung. 

Occasionally  we  meet  under  the  outer  half  of  the  left  clavicle 
with  a  pulsating  tumor  presenting  thrill  and  murmur,  and  dilated 
veins  above.  These  signs  may  be  supposed  to  indicate  a  sub- 
clavian or  axillary  aneurism ;  but  they  often  suddenly  disappear. 
These  "  mimic"  or  phantom  aneurisms  *  are  apt  to  come  back  after 
excitement  and  after  movement  of  the  arms.  They  are  thought 
to  be  due  to  temporary  dilatation  of  the  artery  from  vaso-motor 
paralysis,  limited  to  a  large  vessel  or  to  part  of  it. 

*  See  paper  by  Samuel  West,  St.  Barthol.  Hosp.  Kep.,  1880. 


CHAPTER    V. 

DISEASES   OF   THE   MOUTH,  PHARYNX,    AN"D   (ESOPHAGUS. 

The  diseases  of  this  part  of  tlie  digestive  system  need  not  here 
be  described  at  any  length,  because  many  of  them  liavc  ab'cady 
been  considered  in  treating  of  the  aifections  of  the  kirynx  and  of 
the  heart  and  great  vessels.  But  with  the  maladies  of  this  part 
of  the  body  may  be  considered  the  enlargement  of  glands  at  the 
angle  of  the  jaw,  as  happens  in  mumps. 

MOUTH. 

Soreness  of  the  mouth,  pain  in  masticating,  and  a  fetid  breath 
are  often  complained  of  in  diseases  of  the  oral  cavity.  Let  ns 
suppose  a  patient  to  present  himself  with  such  symptoms.  The 
interior  of  the  mouth  is  exposed  to  a  strong  light,  and  its  different 
parts  are  inspected. 

Tlie  gums  are  noticed  to  be  swollen  and  injected,  and  the  mucous 
membrane  lining  the  cheeks  reddened. — This  is  a  state  of  things 
observed  in  the  different  forms  of  stomatitis.  In  tlie  common 
diffused  inflammcdion,  the  result  of  direct  irritation,  such  as  of 
the  swallowing  of  hot  liquids  or  of  corrosive  substances,  or  an 
accompaniment  and  consequence  of  gastric  disorder,  the  redness  is 
marked;  any  attempt  at  chewing  is  painful;  the  taste  is  impaired; 
a  flow  of  saliva  takes  j)lace  from  the  mouth,  and  superficial  ulcer- 
ations occur  at  its  various  parts.  In  mercurial  stomatitis  there 
are  much  the  same  symptoms;  but  the  more  copious  discharge  of 
saliva,  the  pain  in  the  jaws,  the  loosening  of  the  teeth,  the  enlarged 
tongue,  exhibiting  their  impress,  the  painful  and  swollen  state  of 
the  salivary  glands,  and  the  peculiar  nauseous  breath,  testify  to  the 
specific  character  of  the  inflammation.  The  sore  mouth  of  scurvy 
may  be  distinguished  from  either  of  the  preceding  forms  by  the 
spongy,  purplish,  or  livid  ginns,  which  bleed  on  the  slightest 
462 


DISEASES   OP   THE   MOUTH,  PHARYXX,  ETC.  463 

touch,  by  the  eruption  on  the  skin,  and  by  the  otlier  signs  which 
attend  a  scorbutic  state. 

The  gums  and  the  inside  of  the  cheeks  and,  lips  are  covered  vAth 
a  whitish  curd-like  exudation. — This  constitutes  the  form  of  stom- 
atitis known  as  thrush,  so  frequent  in  infants  at  the  breast,  and  so 
constantly  associated  with  intestinal  disorder,  with  diarrhoea,  with 
colicky  pains,  and  with  a  feverish  heat  of  skin  and  a  hot,  dry 
mouth.  Very  similar  to  it,  regarded  indeed  by  some  as  identical, 
is  the  aphthous  ulceration,  to  which  adults  as  well  as  children  are 
liable.  Here,  too,  a  whitish  deposit  is  perceived  in  various  parts 
of  the  mouth ;  it  is  apt  also  to  be  combined  with  thirst  and  with 
gastric  or  intestinal  disturbance,  and  the  breath  has  a  very  disagree- 
able odor.  The  recognized  difference  consists  in  the  presence  of 
the  small  ulcers  which  may  be  detected  when  the  white  crusts  that 
cover  them  are  removed,  and  in  the  vesicular  nature  of  the  disease 
during  its  formative  stage.  Then  more  or  less  redness  surrounds 
each  spot,  the  ulcers  are  slightly  raised  at  their  borders,  bleed 
easily  on  pressure,  and  may  be  irregular  from  several  running 
together;  their  grayish  covering  is  found  to  be  soluble  in  ether, 
and  to  present  many  oil-globules  under  the  microscope.  On  the 
other  hand,  this  instrument  shows  us  in  thrush  a  special  parasitic 
formation,  the  oidium  albicans. 

Ulcerations  are  perceived  on  the  gums,  tongue,  and  various  parts 
of  the  mouth. — We  meet  with  ulcers  in  the  ordinary,  in  the  mer- 
curial, in  the  scorbutic,  and  in  the  aphthous  inflammation  of  the 
mouth.  But  ulceration  is  apt  to  exhibit  its  most  horrible  features 
in  the  sore  mouth  of  syphilis,  and  in  that  essentially  ulcerative  dis- 
ease called  cancrum  oris,  or  ulcerative  stomatitis.  In  the  former 
the  fauces  as  well  as  the  mouth  are,  as  a  general  rule,  involved, 
and  the  ulcers  show  peculiarities  which  we  shall  presently  study. 
The  latter  is  an  affection  which  prevails  especially  in  enfeebled 
constitutions.  It  is  seen  chiefly  in  hospitals,  and  not  uncommonly 
in  epidemics.  It  begins  with  pain  in  the  gums,  and  these  soon 
swell,  redden,  and  bleed  readily.  They  are  covered  with  a  soft, 
grayish  exudation,  which  often  extends  to  the  soft  palate.  If  the 
layer  of  exudation  be  scraped  away,  a  bleeding,  ulcerated  mucous 
membrane  comes  into  view,  provided  the  swelling  be  not  so  great 
as  to  render  a  careful  examination  of  the  mouth  impossible.  The 
breath  is  most  offensive;  there  is  usually  fever;  yet  the  disease 


464  MEDICAL    DIAGNOSIS. 

does  not  uniformly  progress  with  activity  :  it  may  last  for  weeks, 
or  even  for  months.  Owing  to  the  ulceration  and  to  the  extreme 
fetor  of  tire  breath,  it  is  often  mistaken  for  gangrene  of  the  mouth. 
But,  although  it  may  terminate  in  gangrene,  it  does  not  do  so  of 
necessity.  It  is  a  far  less  serious  complaint,  runs  a  less  speedy 
course,  presents  a  breath  fetid,  it  is  true,  but  not  of  the  peculiar 
gangrenous  odor,  and  lacks  the  very  symptoms  ^^•hich  gangrene 
within  tiie  mouth  gives  rise  to, — the  rapid  extension  of  the  idcer- 
ation;  the  dark-gray  tint  around  it ;  the  extensive  swelling  of  the 
cheek ;  its  altered  color  and  partial  destruction  ;  the  constant  and 
profuse  flow  from  the  mouth  of  blood  or  jdus  mixed  with  saliva; 
and  the  laying  bare  of  the  bones  and  loosening  of  the  teeth. 

The  tongue  is  red  and  sivollen. — Changes  in  color  and  in  ap- 
pearance of  the  tongue  occur  in  general  diseases  of  the  system, 
and  more  especially  in  those  of  the  alimentary  canal.  The  tongue 
is  also  more  or  less  involved,  at  all  events  its  mucous  membrane 
is,  in  the  different  forms  of  stomatitis.  An  abnormal  state  of  the 
covering  of  the  tongue  is,  therefore,  far  from  being  a  sign  that  the 
organ  itself  is  primarily  affected. 

Occasionally,  however,  we  do  meet  ^^-ith  affections  of  its  deeper 
structures.  Its  nerves  may  be  the  seat  of  violent  neuralgia  ;  its 
muscles  may  be  paralyzed ;  it  may  become  hypertrophicd  or  can- 
cerous ;  it  may  undergo  progressive  atrophy ;  or  it  may  be  in  a 
state  of  acute  inflammation.  The  latter  is,  perhaps,  the  most 
frequent  of  its  maladies,  and  is  readily  recognized  by  the  red, 
swollen  look  of  the  organ,  joined  to  a  burning  pain  in  it,  and 
either  to  great  dryness  of  the  mouth  or  to  constant  dribbling. 
The  swelling  usually  begins  at  the  anterior  portion,  and  may 
become  so  considerable  as  to  threaten  suffocation;  the  inflamed 
tongue  fills  up  the  fauces  and  protrudes  out  of  the  mouth,  and 
the  unhappy  patient  can  neither  swallow  nor  utter  a  word.  He 
has  active  fever,  headache,  great  restlessness,  and  intense  thirst, — 
symptoms  which  last  for  several  days,  and  until  the  inflammation 
subsides.  But  unless  properly  treated,  and  sometimes  in  spite  of 
proper  treatment,  the  inflammation  runs  on  to  suppuration  or  gan- 
grene. In  some  instances  it  leaves  a  pernlanent  induration,  which 
may  be  mistaken  for  a  cancerous  nodule.  Acute  glossitis  is  a  dan- 
gerous complaint ;  fortunately,  it  is  a  rare  one.  Its  most  frequent 
cause,  as  now  seen,  is  direct  injury,  either  from  wounds  or  the 


DISEASES    OF    THE    MOUTH,  PIIAEYNX,   ETC.  465 

stings  of  venomous  insects,  or  from  the  introduction  of  corrosive 
substances  into  the  mouth.  Its  most  frequent  cause  formerly 
was  the  abuse  of  mercury  pushed  to  salivation.  At  times  it  is 
observed  as  a  complication  of  scarlatina  and  of  erysipelas. 

Other  affections  of  the  tongue  connected  with  diseases  of  its 
structure  have  been  mentioned  in  the  first  part  of  this  volume. 
Cancer  of  the  tongue  produces  the  greatest  alteration  in  the  form 
and  texture  of  the  organ.  Syphilis  of  the  tongue  gives  rise  to 
deep  fissures,  ulcers,  and  gummous  nodules  which  may  be  difficult 
to  .distinguish  from  cancer,  except  by  the  history  and  the  absence 
of  pain.  As  a  sign  of  recovery  from  syphilis,  the  tongue  may 
present  a  quite  peculiar  indented  appearance,  similar  to  what  is 
seen  in  the  syphilitic  liver. 

FAUCES. 

The  fauces — that  is,  the  parts  at  the  back  of  the  mouth  which 
are  brought  into  view  when  the  lips  are  widely  opened,  such  as 
the  half-arches,  the  uvula,  the  tonsils,  the  posterior  wall  of  the 
pharynx — may  be  involved  in  the  same  diseases  as  the  parts  situ- 
ated in  front.  The  contiguity  of  these  structures  is  in  fact  such 
that  any  morbid  action  is  apt  to  spread  to  them,  or  to  extend  from 
them  either  forward  or  downward  into  the  pharynx,  and  even  into 
the  larynx.  Moreover,  on  this  very  account  a  disorder  is  rarely 
found  limited  to  any  one  portion  of  the  fauces,  but  transfers  itself 
generally  from  one  to  the  other,  from  the  tonsils  to  the  soft  pal- 
ate, from  the  soft  palate  to  the  tonsils.  The  most  common  aifec- 
tions  of  the  fauces  are  inflammation  and  ulceration,  both  of  which 
occasion  a  feeling  of  uneasiness  in  the  throat,  and  also  difficulty 
or  pain  in  deglutition,  and  both  of  which  are  readily  enough 
detected  by  looking  into  the  mouth  when  the  jaws  are  widely 
separated  and  the  tongue  depressed. 

In  the  ordinary  inflammation  of  the  fauces,  the  simple  angina, 
or  sore  throat,  the  parts  are  of  a  bright-red  color,  and  the  uvula  is 
long  and  swollen,  and  by  dropping  on  the  tongue  gives  rise  to  a 
constant  disposition  to  swallow,  although  the  act  of  swallowing  is 
attended  with  pain.  Associated  with  the  angina  are  coryza  and 
febrile  disturbance;  and,  owing  to  the  inflammation  travelling 
up  the  Eustachian  tube,  the  sense  of  hearing  is  impaired. 

30 


466  MEDICAL   DIAGNOSIS. 

Tonsillitis. — Wlicn  the  inflammation  penetrates  the  substance 
of  the  tonsils,  or  in  (juinsi/,  much  the  same  general  symptoms 
occur  as  in  ordinary  angina.  But  the  sense  of  constriction  in  the 
throat  is  greater ;  so  is  the  difficulty  in  swallowing  ;  and  liquids 
arc  apt  to  return  through  the  nose.  The  voice  is  thick,  and  has 
often  a  peculiar  sound ;  it  is  painful  to  the  patient  to  talk,  and  on 
looking  into  the  throat  the  tonsils  may  be  seen  red,  prominent, 
and  covered  with  mucus  which  is  not  easily  detached.  Sometimes 
the  swelling  is  so  considerable  that  the  tumid  glands  fill  up  the 
space  between  the  half-arches  and  leave  but  a  small  interval  for 
the  passage  of  food  or  drink.  In  some  instances  we  cannot  sep- 
arate the  jaws  sufficiently  to  get  a  view  of  tlie  throat,  and  have  to 
trust  to  the  introduction  of  the  finger  to  tell  us  the  condition  of 
the  affected  parts.  Occasionally  the  inflammation  extends  from 
the  tonsils  to  the  salivar}^  glands ;  the  submaxillary  and  parotid 
glands  swell,  and  ptyalism  takes  place.  It  is  necessary  to  be 
aware  of  this  fact ;  for,  if  a  mercurial  cathartic  has  been  admin- 
istered, the  profuse  flow  of  saliva  might  be  incorrectly  attributed 
to  it. 

There  is  not  much  likelihood  of  confounding  this,  a  form  of 
secondary  parotitis,  with  mumps,  in  w-hich  an  outward  swelling, 
visible  beneath  the  ear,  is  found,  but  not  a  swelling  within  the 
throat,  and  in  which  no  real  difficulty  in  swallowing  occurs, 
except,  perhaps,  when  the  tumefaction  is  at  its  height. 

Tonsillitis  terminates  by  resolution  or  by  the  formation  of  pus. 
There  are  no  positive  means  of  ascertaining  that  the  inflammation 
is  going  to  end  in  suppuration,  although  we  may  suspect  that  this 
will  be  the  case  when  much  pain  is  felt  at  the  angles  of  the  jaws 
and  shooting  to  the  ear,  and  wdien  the  symptoms  have  been  severe 
and  persistent  for  more  than  four  or  five  days.  Sometimes  the  pus 
may  be  seen  through  the  covering  of  the  tonsils ;  but  often  the 
vast  sense  of  relief  experienced  by  the  patient,  and  the  sudden 
improvement  in  deglutition,  attended,  perhaps,  with  an  unpleas- 
ant taste,  are  the  only  signs  that  the  collection  of  pus  has  been 
discharged.  Attacks  of  tonsillitis  are  prone  to  be  repeated, 
and  may  lead  to  permanent  enlargement  and  induration  of  the 
tonsils.  The  enlarged  tonsils,  attended  as  they  frequently  are 
with  cervical  glandular  swellings,  may  be  mistaken  for  cancer 
of  the  tonsils.     But  in  this  affection  sanious  offensive  ulcerations 


DISEASES    OF    THE    MOUTH,   PHARYNX,  ETC.  4G7 

"  occur.*  Acute  tonsillitis  may  be  seen  in  connection  with  malaria. f 
At  times  the  tonsils  become  gangrenous.^ 

Diphtheria. — There  is  another  kind  of  affection  of  the  fauces 
which,  in  accordance  with  the  clinical  classification  followed  in  this 
work,  may  be  considered  here, — membranous  angina  or  diphtheria. 
Not  that  it  is  a  local  malady.  On  the  contrary,  it  is  a  general 
disease,  of  which  the  exudative  inflammation  of  the  throat  is 
merely  the  most  usual  characteristic.  Yet  the  local  lesion  is  so 
marked,  and  the  symptoms  are  so  nearly  related  to  those  of  the 
common  forms  of  acute  sore  throat,  that  practicall}^  the  disorder 
is  best  regarded  in  connection  with  them. 

It  begins  usually  as  an  ordinary  sore  throat,  with  redness  and 
swelling  of  the  arches  of  the  palate,  and  of  the  tonsils.  There  is 
a  slight  stiffness  of  the  neck,  and  the  cervical  and  submaxillary 
glands  of  the  jaw  are  enlarged  and  tender,  and  the  subcutaneous 
tissue  may  become  involved  in  the  swelling.  Within  a  period 
varying  from  a  few  hours  to  a  few  days,  an  exudation  takes  place 
on  the  tonsils,  the  uvula,  and  the  soft  palate.  This  exudation  is 
more  or  less  extensive,  generally  tough,  and  of  a  white  or  grayish 
hue.  It  may  show  but  little  tendency  to  spread ;  or  it  may 
extend  to  the  gums  and  along  the  walls  of  the  pharynx,  and  into 
the  windpipe.  In  some  cases  it  passes  u]3ward  into  the  nares, 
yet  it  may  begin  there  simultaneously  with  its  appearance  in 
the  throat.  The  false  membrane,  once  formed,  darkens,  wastes 
from  the  circumference  toward  the  centre,  and  gradually  dis- 
appears. But  sometimes  the  coat  becomes  for  a  time  thicker  and 
thicker  by  the  constant  addition  of  fresh  layers.  This  happens 
particularly  in  the  "  croupous  form"  of  diphtheria,  in  which  the 
inflammation  is  more  intense  from  the  onset,  and  fibrin  is  freely 
poured  out,  not  simply  into  the  epithelium,  but  into  the  tissues 
underneath,  and  in  which  the  fibrinous  exudations  succeed  one 
another  rapidly  until  the  dense  thick  coating  of  false  membrane 
results.  Under  any  circumstances,  when  artificially  removed, 
•  the  pseudomembrane  is  soon  developed.  After  the  first  week 
from  its  beginning,  no  further  exudation  is  apt  to  happen,  and 


*  Poland,  Brit,  and  For.  Med.-Chir.  Eev.,  April,  1872. 

t  Chassaignac,  New  Orleans  Med.  and  Surg.  Journ.,  Oct.  1888. 

J  Cragin,  New  York  Med.  Journ.,  Sept.  1, 


468  MEDICAL   DIAGNOSIS. 

tlie  dano-er  arising;  from  the  membrane  mav  be  o:enerQllv  looked 
ii])Ori  as  over,  unless,  as  is  not  uncommon,  a  relapse  of  the  malady 
occur. 

The  constitutional  symptoms  vary  greatly.  The  pulse  may  be 
frequent,  the  skin  hot,  and  there  may  be  much  pain  in  the  head ; 
in  fact,  the  symptoms  are  those  of  fever,  with  a  temperature  of 
102°  to  103°.  Yet  the  temperature  is  most  variable;  there  is 
often,  even  in  the  worst  cases,  an  almost  normal  temperature.  A 
sense  of  weakness  and  prostration  are  always  prominent  from  the 
onset.  In  some  instances,  typhoid  phenomena  manifest  them- 
selves, especially  when  decomposition  of  the  disintegrating  exu- 
dation takes  })lace,  giving  rise  to  the  se])tic  form  of  the  malady ; 
in  this  the  temperature  may  be  even  below  the  normal.  The 
nervous  system  becomes  much  affected,  and  the  tendon  reflexes 
are  lost.''- 

In  diphtheria  the  danger  is  twofold  :  it  arises  partly  from  the 
depressing  effect  of  the  poison,  increased  as  this  effect  may  be  by 
the  absorption  of  putrid  matter  from  the  throat ;  partly  from  the 
extension  of  the  disease  to  the  larynx  and  lungs.  Again,  at  the 
height  or  even  at  the  decline  of  the  malady  there  is  risk  of  heart- 
palsy  or  heart-clot.  Nor  is  the  termination  of  the  acute  disorder 
always  the  termination  of  the  complaint.  A  chronic  irritation  of 
the  throat,  lasting  weeks  or  months,  and  possibly  relapsing,  under 
exposure,  into  a  diphtheritic  sore  throat,  remains;  or  albuminuria, 
which,  indeed,  shows  itself  during  the  height  of  the  malady,  but 
which  also  outlasts  its  acute  manifestations ;  or  pleurisy,  or  bron- 
chitis and  pneumonia, — both  of  which  may  be  delayed  until  after 
the  exudation  has  disappeared  from  the  throat, — increase  the  list 
of  the  complications  of  the  affection,  and  protract  or  imperil  the 
convalescence.  And  there  are  morbid  conditions  which  may  be 
wholly  looked  upon  as  after-symptoms.  A  paralysis  of  the  velum 
palati  and  of  the  pharyngeal  arches,  making  itself  apparent  by 
a  peculiar  nasal  intonation  of  the  voice,  and  by  proneness  to  re- 
gurgitation of  fluids  through  the  nostrils,  is  among  the  earliest  of 
them,  manifesting  itself  often,  indeed,  just  at  the  termination  of 
the  acute  malady.  Later  ap])ear  impairment  of  vision,  gastro- 
dynia,  ulcers  in  various  parts  of  the  body,  profound  anaemia,  and 

*  McDonnell,  Medical  News,  Oct.  15,  1887. 


DISEASES   OF   THE   MOUTH,  PIIAKYNX,  ETC.  469 

that  gradual  failing  of  muscular  power  with  numbness  which  ordi- 
narily does  not  take  place  until  after  complete  convales('ence,  and 
which  winds  up  in  almost  total  loss  of  muscular  force  with  antcs- 
thesia,  and  absence  of  reflexes,  constituting  dij)htheritic  paralysis. 
Furthermore,  I  have  known  aphasia  to  follow  the  depressing 
complaint. 

But  to  look  at  the  diiFerential  diagnosis  of  the  disorder.  It 
varies  widely  from  stomatitis,  from  tonsillitis,  from  pharyngitis, 
— in  truth,  from  all  the  ordinary  local  inflammations  of  these 
structures, — by  the  presence  of  a  membrane,  by  the  striking  con- 
stitutional symptoms,  and  by  the  sequelae. 

Yet  there  are  certain  sources  of  error  against  which  it  is  neces- 
sary to  guard.  In  simple  pharyngitis,  a  mass  of  mucus,  in  part 
derived  from  the  nares,  is  apt  to  collect  on  the  inflamed  mem- 
brane, and  looks  at  first  sight  like  the  coating  from  an  exudation  ; 
but  it  may  be  easily  removed,  and  a  closer  inspection  proves  its 
true  nature.  In  tonsiUiUs,  liquid  may  ooze  from  the  openings  of 
the  follicles  on  the  surface  of  the  swollen  tonsils,  or  little  yellow- 
ish or  whitish  points  form  there.  But  they  are  very  limited,  are 
strictly  confined  to  the  gland,  exhibit  no  tendency  to  spread  or  to 
coalesce,  are  generally  small  white  specks  of  roundish  or  oval 
shape,  and,  when  cast  ofl",  superficial  ulcerations  are  seen  on  the 
gland.  I  desire  particularly  to  call  attention  to  the  possibility  of 
confounding  these  appearances,  which  are  by  no  means  uncommon 
in  some  forms  of  tonsillitis,  with  diphtheria,  for  I  have  known 
them  to  occasion  more  than  one  mistake.  The  mistake  is  most 
likely  to  happen  in  those  mild  cases  of  the  disease  in  Avhich  the 
exudation  is  limited,  and  the  injection  or  superficial  inflammation 
of  the  tonsils  and  back  of  the  throat  marked,  which  are  some- 
times described  as  the  "catarrhal  form"  of  diphtheria.  Should, 
in  an  individual  instance,  the  facts  mentioned  be  insufficient  to 
solve  the  doubt,  the  microscope  can  do  so ;  for  it  show^s  the  white 
masses  to  be  largely  composed  of  epithelium,  and  not,  like  the 
diphtheritic  membrane,  mainly  of  fibrillated  fibrin,  of  granular 
corpuscles,  and  of  pus,  besides  epithelium  in  different  degrees  of 
development  and  retrograde  change,  and  fungoid  masses.*  Even 
on  the  most  superficial  layers  of  the  epithelium  micrococci  show 

*  Senator,  Klinische  Vortrage,  1874. 


470  •        MEDICAL    DIAGNOSIS. 

themselves  at  once  ;  these  penetrate  into  the  deeper  layers,  bv  what 
Oertel  calls  a  micrococcus  vegetation.  It  is,  however,  still  uncer- 
tain whether  specific  diphtheritic  bacteria  exist.  The  observations 
of  Wood  and  Formad,*  and  the  statements  of  Perls,t  throw  doubt 
on  the  matter. 

Zlccrafive  stomatitis,  the  form  of  stomatitis  most  likely  to  be 
confounded  with  diphtheria,  and  especially  with  this  malady  when 
the  exudation  lines  the  gums,  is  discriminated  by  the  ulceration 
or  sloughing  ;  whereas  the  mucous  mcmlirane  in  the  pseudomem- 
branous disease  remains  intact,  save  in  tlie  rarest  instances.  The 
same  feature  distinguishes  diphtheria  from  gangrene  of  the  mouth, 
for  which,  on  account  of  the  extreme  fetor  of  the  breath,  it  is  some- 
times mistaken,  and  aids  in  distinguishing  it  also  from  other  kinds 
of  stomatitis,  as  from  thrush.  In  the  latter,  too,  the  buccal  mucous 
membrane,  and  not  the  throat,  is  chiefly  affected,  and  the  abdom- 
inal symptoms,  and  the  other  constitutional  phenomena,  are  dif- 
ferent. So  are  they  in  aphthse,  in  which,  moreover,  the  superficial 
ulcerations,  which  bleed  when  touched,  the  unbroken  vesicles  or 
pustules  in  other  parts,  and  the  seat  of  the  disorder — usually  on 
the  edge  of  the  tongue,  on  the  internal  surface  of  the  lips,  and 
on  the  gums  and  inside  of  the  cheek — are  points  to  be  taken  into 
account. 

Besides  these  affections,  there  are  others  which  must  be  distin- 
guished from  diphtheria.  We  occasionally  find  cases  occurring 
in  epidemics,  and  where  the  membrane  is  limited  nearly  altogether 
to  the  follicles,  and  chiefly  to  the  tonsils.  As  the  membrane 
passes  away,  ulcerations  are  obvious.  Swelling  of  the  glands 
of  the  neck,  and  fever,  but  not  of  acute  type,  attend  this  ulcero- 
membranous angina,  which,  moreover,  shows  a  strong  disposition 
to  relapses.  But,  though  kindred  to  diphtheria,  and  in  isolated 
instances  perhaps  difficult  to  discriminate,  it  differs  from  it  in  its 
seat  and  in  its  want  of  tendency  to  spread,  in  the  formation  of 
superficial  ulcers,  in  its  less  marked  constitutional  depression,  and 
in  its  invariably  favorable  termination,!  It  is  similar  to  herpes 
of  the  tonsils,  described  by  Trousseau.      Whether  there  be  not 


*  Supplement  No.  17,  National  Board  of  Health  Bulletin,  Jan.  21,  1882. 
f  Lehrbuch  der  Allgemeine  Pathologie. 

X  See  a  paper  in  which  I  have  described  an  epidemic  of  the  kind,  in  the 
Amer,  .Journ.  Med.  Sci.,  July,  1870. 


DISEASES   OF   THE    MOUTH,   PHARYNX,   ETC.  471 

also  other  kinds  of  membranous  sore  throat  to  be  separated  from 
true  diphtheria,  is  a  matter  requiring  further  investigation. 

There  is  an  acute  disease  of  the  throat  to  whicli  Todd  especially 
has  called  attention,*  and  which  presents  also  some  strong  points 
of  similitude  to  diphtheria, — erysipelas  of  the  fauces.  Like  diph- 
theria, it  is  a  most  dangerous  ailment ;  as  in  diphtheria,  the 
morbid  process  may  extend  to  the  larynx ;  as  happens  often  in 
diphtheria,  the  mucous  membrane  may  exhibit  a  peculiar  dusky- 
red  color ;  as  in  diphtheria,  the  poison  paralyzes  the  muscles  of 
the  palate  and  pharynx,  and  liquids  are  apt  to  be  rejected  through 
the  nostrils  and  mouth.  But  the  difficulty  in  deglutition  differs 
from  that  of  diphtheria  in  being  present  from  the  onset,  and  is 
not  attended  with  enlargement  of  the  glands  of  the  neck,  or  with 
the  formation  of  a  false  membrane.  In  some  instances,  too,  we 
find  vivid  redness  of  the  throat,  which  may  be  associated  with 
much  swelling.  If  the  erysipelatous  inflammation  extend  to  the 
larynx,  there  is  local  pain,  with  urgent  dyspnoea  and  hoarseness ; 
and  usually  rapid  exhaustion  supervenes.  In  cases  of  this  kind, 
the  submucous  tissues  of  the  larynx  are  found  extensively  infil- 
trated with  pus.  The  cases  may  happen  Avithout  erysipelas  show- 
ing itself  on  any  external  part  of  the  body ;  on  the  other  hand, 
erysipelas  beginning  in  the  fauces  may  spread  to  the  face.f 

This  erysipelas  of  the  fauces  is  not  a  frequent  disease  ;  and  it 
must  be  stated  that  there  are  cases  of  diphtheria  which  simulate 
it  very  closely.  I  have  seen  a  number  of  instances  of  the  malady 
in  which  the  whole  mucous  membrane  was  of  a  vivid  or  dusky 
hue  ;  in  which  there  was  much  swelling,  with  an  effusion  of  serum, 
especially  in  the  submucous  tissue  of  the  uvula,  causing  it  to  look 
like  a  small  transparent  bag  ;  in  which  immense  difficulty  or  even 
impossibility  in  deglutition  existed, — yet  in  which  no  membrane 
appeared  for  days  after  the  violent  inflammation  of  the  throat  had 
,set  in,  and  was,  Avhen  it  showed  itself,  very  slight  in  extent,  and 
out  of  all  proportion  to  the  inflammation.  But  the  constitutional 
symptoms  and  the  sequelae  w^ere  the  same  as  those  of  ordinary 
diphtheria.  In  one  of  the  cases  of  the  kind  referred  to,  suppu- 
ration of  one  of  the  tonsils  took   place  in  consequence  of  the 

*  Clinical  Lectures  on  Acute  Diseases. 

f  Cases  quoted  in  Schmidt's  Jahrbiiclier,  1869,  No.  1. 


472  MEDICAL    DIAGNOSIS. 

inflaniniation;  a  lavcr  of  deposit  liad  coated  parts  of  the  tonsils 
and  of  the  half-arches  and  nvnla. 

How  shall  we  separate  diphtheria  from  membrcoious  crouj),  a 
disease  with  which,  indeed,  it  is  by  many  regarded  as  identical  ? 
Yet  this  seems  taking  a  narrow  view  of  the  facts.  In  the  first 
place,  croup  is  a  local  complaint,  and  lacks  the  peculiar  constitu- 
tional symptoms,  the  early  depression,  and  the  sequels  of  diphthe- 
ria. Secondly,  an  affection  of  the  windpi])e  is  not  by  any  means 
an  essential  element  of  diphtheria,  for  in  the  majority  of  cases  the 
disease  does  not  spread  to  the  larynx.  Thirdly,  when,  from  the 
paroxysms  of  hoarse,  irritative  cough,  the  labored  breathing,  the 
attacks  of  suffocation,  the  liuskiness  or  extinction  of  voice,  we  may 
infer  that  the  exudative  process  has  reached  the  larynx, — when,  in 
other  words,  the  symj^toms  of  croup  arise, — we  still  recall  that  the 
first  manifestations  of  the  membranous  affection  were  perceived  in 
the  throat,  and  not  in  the  larynx.  Indeed,  save  in  the  rarest  cases, 
the  disease  does  not  begin  in  the  windpipe ;  though  the  beginning 
above  may  not  attract  attention,  and  may  be  most  readily  over- 
looked. Tims,  laryngeal  diplitheria  affects  primarily  the  throat, 
and  may  extend  to  the  windpipe ;  membranous  croup  affects  prima- 
rily the  windpipe,  and  may  extend  to  the  throat.  Fourthly,  croup 
is  not  contagious,  as  \\q  find  diphtheria  is.  And,  even  granting 
that  as  regards  the  membrane  and  the  symptonis  we  may  not  be 
able  to  distinguish  individual  cases  of  membranous  croup  from 
laryngeal  diphtheria,  the  origin  of  the  diphtheritic  complaint, 
and  its  spreading  to  other  members  of  the  household,  if  not  in  a 
membranous  form  yet  in  the  form  of  sore  throat  Avith  singular 
constitutional  depression,  show  its  peculiar  and  special  traits. 

On  one  symptom  we  cannot  lay  as  much  stress  as  might  be 
supposed.  Albuminuria,  the  elaborate  report  of  the  committee 
of  the  Medico-Chirurgical  Society  has  taught  us,*  is  not  always 
present  in  laryngeal  diphtheria,  owing  to  the  early  fatality  of  the 
malady ;  again,  in  certain  cases  the  mere  dyspnoea  of  laryngitis 
may  give  rise  to  albumen  in  the  urine.  Yet  when  albuminuria 
is  marked,  and  when  it  has  happened  where  an  affection  of  the 


*  Medico-Chirurgical  Transactions,  vol.  Ixii.,  1879.  Some  of  the  anatomical 
points  involved  are  also  well  discussed  by  Weigert  in  Virchow's  Archiv,  vols. 
Ixx.  and  Ixxi. 


DISEASES   OF   THE   MOUTH,  PHARYNX,  ETC.  473 

fauces  has  preceded  the  laryngeal  implication,  it  points  to  an 
infective  cause, — to  laryngeal  diphtheria. 

Lastly,  diphtheria  may  be  confounded  with  scarlatina.  When, 
indeed,  we  reflect  on  the  similar  appearance  of  the  throat,  on  the 
occurrence  of  albuminuria  in  both  maladies,  and  on  the  frequency 
with  which  both  are  found  to  prevail  at  the  same  time  as  epidemics 
in  a  community,  it  is  not  astonishing  that  one  should  be  looked 
upon  as  but  a  modified  form  of  the  other.  Allied  they  certainly 
are,  but  not  identical ;  for  the  poison  of  one  leads  to  a  thoroughly- 
defined  rash,  and  leaves  a  protective  influence  against  a  second 
attack,  and  often  also  deafness,  suppuration  of  the  glands  of  the 
neck,  and  dropsy, — phenomena  which  are  not  encountered  in  the 
other.  It  is  true  that  in  very  rare  instances  of  diphtheria  we  en- 
counter a  slight  erythema  of  the  neck  and  breast,  but  it  is  not  like 
the  vivid,  diffused  rash  of  scarlet  fever.  Moreover,  the  exudation 
in  the  throat  is  not  exactly  similar  in  the  two  diseases.  In  scar- 
latina it  is  pultaceous,  and  not  coherent,  and  has  no  tendency  to 
spread  to  the  respiratory  passages.  Then  the  albuminuria  hap- 
pens at  a  different  period.  In  scarlatina  it  is  a  sequel  rather  than 
a  concomitant ;  in  diphtheria  it  is  a  concomitant  rather  than  a 
sequel.  Further,  the  gravity  of  the  symptom  is  not  the  same. 
In  the  latter  malady  it  is  an  indication  of  danger ;  it  has  not  so 
serious  a  meaning  in  the  former. 

Diphtheria  may  be  intercurrent  in  various  maladies :  in  typhoid 
fever,  in  the  exanthemata,  in  pneumonia.  Nor  is  the  exudation 
always  restricted  to  the  throat.  It  may  show  itself  in  a  wound 
or  on  excoriated  skin,  on  the  nasal  mucous  membrane,  the  con- 
junctiva, the  nipple,  the  uvula,  or  around  the  anus;  it  may  be 
found  coating  the  stomach,  the  intestines,  and  the  ramifications 
of  the  bronchial  tubes. 

Nasal  diphtheria  is  a  very  grave  form  of  the  malady  :  it  may 
either  be  present  alone,  or  coexist  with  a  deposit  in  the  fauces 
and  pharynx.  It  generally  occurs  with  evidences  of  the  septic 
form ;  the  symptoms  are  of  a  low  type,  and  we  recognize  the 
affection  by  carefully  inspecting  the  posterior  pharynx  and  seeing 
that  the  membrane  extends  upward ;  by  noting  the  irritated,  red- 
dened look  of  the  nostril,  even  when  no  membrane  can  be  dis- 
cerned in  it ;  and  by  the  coryza,  the  sense  of  obstruction  in  the 
nose,  and  the  acrid  sanious  discharge  which  comes  from  it.     In 


474  MEDICAL   DIAGNOSIS. 

cases  in  which  tlic  nasal  (hict  and  the  larvngeal  canal  are  stopped 
up  by  tlie  false  membrane,  tears  are  constantly  rolling-  down  the 
cheeks.  Epistaxis  is  a  not  uncommon  symptom  ;  swelling  of  the 
cervical  glands  may  or  may  not  be  })resent. 

Mumps. — This,  like  diphtheria,  is  a  general  disease,  and  is 
only  here  described  as  a  matter  of  clinical  convenience.  Parotitis 
is  most  commonly  seen  as  an  epidemic  malady ;  but  we  occasion- 
ally encounter  a  secondary  parotitis  following  typhus  fever,  scarlet 
fever,  smallpox,  measles,  and  dysentery.  In  this  form  suppura- 
tion is  much  more  common  than  in  ordinary  mumps.  The  dis- 
ease generally  begins  \^'ith  pains  at  the  angle  of  the  jav\^,  which  are 
soon  followed  by  a  marked  swelling,  first  on  one  side,  then  on  the 
other,  which  results  in  the  head  being  kept  rigid.  The  tumid 
glands  are  sore,  and  become  more  painful  during  attempts  at 
swallowing  and  chewing,  though  there  is  really  little,  if  any, 
diiificulty  in  swallowing.  If  the  patient  be  made  to  swallow 
slowly  ten  to  thirty  drops  of  undiluted  vinegar,  decided  pain  is 
produced  in  the  affected  glands, — an  old  and  useful  diagnostic 
test,  to  which  Dr.  Louis  Starr  called  my  attention.  The  mouth 
is  generally  filled  with  saliva,  though  it  may  be  very  dry ;  and 
the  hearing  may  be  impaired,  or,  for  the  time  being,  entirely 
lost,  and  ringing  in  the  ears  is  very  common.  The  temperature 
generally  ranges  between  101°  and  102°,  but  in  cases  of  orchitis 
following  mumps,  or  of  metastasis,  I  have  seen  it  104°  to  105°. 
The  nervous  system  may  become  decidedly  affected.  Acute  mania 
has  been  known  to  become  associated  with  mumps;  so  has  periph- 
eral neuritis.*  Parotitis  is  easily  recognized.  There  is  no  swelling 
of  the  tonsils,  hence  it  cannot  readily  be  mistaken  for  tonsillitis. 

Chronic  Sore  Throat. — Attacks  of  angina  are  prone  to  re- 
cur, and  to  lead  to  chronic  inflammation  of  the  structures.  Now, 
an  affection  of  this  kind  is  liable,  on  any  exposure,  to  be  kin- 
dled into  the  acute  complaint ;  besides,  it  yields  at  all  times  some 
manifestations  of  a  disorder  of  the  throat.  A  thickening  of  the 
folds  of  membrane  forming  the  half-arches,  a  tumefaction  of  the 
follicles  at  the  upper  jmrt  of  the  pharynx,  a  lengthening  of  the 
uvula,  are  the  visible  signs  of  the  chronic  malady  ;  a  constant 
disposition   to  clear  the   throat,  and  a  dry  cough,  are  often  the 

*  Lancet,  April  9,  1887. 


DISEASES   OF   THE   MOUTH,  PHARYNX,  ETC.  475 

attending  general  symptoms.  Owing  to  the  habitual  coughing, 
the  patient  may  be  suspected  to  be  laboring  under  phthisis,  and 
be  treated  accordingly,  when  the  whole  difficulty  lies  not  in  the 
lungs,  but  in  the  throat.  Yet  an  error  in  the  opposite  direction 
is  perhaps  more  frequently  committed.  Tonsils  and  uvulas  are 
removed,  with  the  view  of  curing  a  cough  which  is  really  kept 
up  by  a  source  of  disturbance  in  the  lungs,  in  forgetfulness  of  the 
fact  that  in  scrofula  and  tuberculosis  chronic  enlargement  of  the 
tonsils  and  follicular  pharyngitis  are  by  no  means  unusual.  A 
careful  examination  of  the  chest  ought  always  to  be  made,  even 
when  inspection  of  the  throat  shows  disease  to  be  there  present. 
On  the  other  hand,  we  may  find  in  the  condition  of  the  throat 
and  of  the  nares  the  explanation  of  thoracic  affections,  for  instance 
of  asthma,  a  number  of  cases  of  which  have  their  origin  in 
irritation  reflected  from  these  parts. 

The  follicular  disease  of  the  throat,  or  "clergyman's  sore  throat," 
is  the  most  frequent  of  all  the  morbid  conditions  which  produce 
a  chronic  sore  throat.  As  Green  pointed  out,  the  abnormal  con- 
dition of  the  follicles  of  the  mucous  membrane  of  the  pharynx 
and  fauces  often  extends  to  the  larynx.  There  are  constant  hawk- 
ing and  attempts  at  clearing  the  throat,  and  not  unfrequently 
roughness  of  voice  or  decided  hoarseness.  On  inspecting  the 
throat,  the  enlarged  mucous  follicles  can  be  readily  discerned  ; 
those  on  the  pharynx  are  very  prominent.  In  cases  of  long  stand- 
ing, the  follicles  may  ulcerate,  and  very  commonly  they  pour  out 
an  acrid  secretion.  But,  unless  from  coexisting  enlargement  of 
the  uvula,  or  an  altered  position  of  the  epiglottis,  or  marked  laryn- 
geal disease,  or  a  bronchial  complication,  there  is  no  decided  cough. 
The  follicular  disease  may  occur  in  consequence  of  repeated  at- 
tacks of  sore  throat,  or  be  an  attendant  upon  gastric  disorder,  or 
follow  constant  exercise  and  straining  of  the  voice. 

Chronic  rheumatic  sore  throat  gives  rise  to  pain  which  is  often 
referred  to  the  hyoid  bone,  is  increased  by  pressure,  -and  is  also 
felt  in  the  tonsils.  Ingals*  points  out  that  the  pain  often  entirely 
disappears  while  the  patient  is  eating,  but  increases  in  cloudy  and 
damp  weather.  There  are  signs  of  slight  congestion  in  the  throat, 
and  generally  in  the  larynx,  yet  mostly  out  of  all  proportion  to 

*  Medical  News,  March,  1890. 


476  MEDICAL   DIAGNOSIS. 

the  pain.    The  general  health  remains  good,  and  we  find  no  fever ; 
there  is  apt  to  be  a  history  of  a  rheumatic  diathesis. 

f7c('/-.sare  not  often  developed  in  the  lances  during  an  attack 
of  acute  inflammation,  except  in  tlie  specific  sore  throat  of  scar- 
latina; in  chronic  inflammation,  especially  if  occurring  in  scrofu- 
lous persons,  they  are  more  common.  The  most  profound  ulcer- 
ations are  those  of  constitutional  syphilis,  implicating,  as  they  do, 
not  only  the  tissues  of  the  fauces,  but  also  the  parts  in  front,  and 
destroying  both  the  fleshy  covering  of  the  bones  and  the  bones 
themselves.  With  regard  to  treatment  and  to  prognosis,  it  is  of 
the  utmost  importance  to  distinguish  these  syphilitic  ulceis  from 
those  produced  by  other  causes.  A  cutaneous  eruption  of  a  syphi- 
litic character,  and  enlarged  lymphatic  glands,  or  the  history  of 
antecedent  syphilis,  would  lead  us  to  a  correct  conclusion ;  but  an 
accurate  history  of  a  syphilitic  infection  cannot  always  be  obtained. 
The  ulcers  themselves  furnish  some  information  by  which  we  may 
suspect  their  origin.  They  are  not  superficial  and  stationary,  like 
those  resulting  from  ordinary  inflammation  ;  on  the  contrary,  they 
are  deep  and  have  a  strong  tendency  to  spread.  They  are  rounded, 
or  of  a  serpiginous  form,  with  borders  well  defined  and  elevated, 
and  surrounded  by  a  distinct  zone  of  redness  ;  and  the  inflamma- 
tion which  precedes  them  is  limited  to  spots,  and  is  not  so  difl'used, 
nor  attended  with  so  much  swelling,  as  the  inflammation  which 
exists  prior  to  simple  ulceration. 

PHAEYNX  AND    (ESOPHAGUS. 

In  describing  the  affections  of  the  fauces,  those  of  that  portion 
of  the  pharynx  which  is  most  usually  the  seat  of  disease  have 
been  at  the  same  time  described.  Indeed,  when  we  speak  of 
acute  or  chronic  pharyngitis,  we  generally  mean  acute  or  chronic 
inflammation  of  the  fauces,  to  which  the  upper  part  of  the  pharynx 
belongs.  Inflammation  of  the  portion  of  the  pharynx  which  is 
out  of  sight  when  the  tongue  is  depressed,  is  rare.  It  may  be 
presumed  to  exist  if  there  be  pain  and  an  impediment  in  swallow- 
ing Avhen  the  food  arrives  opposite  the  top  of  the  larynx,  while 
the  respiration  remains  free  and  the  voice  unaffected.  Abscesses 
sometimes  forrn  between  the  textures  composing  the  pharynx,  and 
between  its  posterior  wall  and  the  cervical  vertebrae.    These  retro- 


DISEASES    OF    THE    MOUTH,   PHARYNX,  ETC.  477 

pharyngeal  ohseesses  mostly  result  from  disease  of  the  vertcbrse. 
They  occasion  great  difficulty  in  deglutition  and  in  breathing;  an 
altered  voice ;  dull  pain  and  stiffness  in  the  neck ;  external  swell- 
ing, which  may  or  may  not  be  oedematous ;  and  commonly  a  tume- 
faction at  the  back  of  the  throat,  which  can  be  seen,  or  which  at 
least  can  be  felt  with  the  finger  pressed  against  the  posterior  wall 
of  the  pharynx.  On  account  of  the  obstructed  respiration  and 
the  changed  voice,  the  disease  is  liable  to  be  mistaken  for  croup. 
Its  differences  have  been  already  enumerated.* 

The  oesophagus  is  not  often  the  seat  of  disease.  We  meet  witli 
acute  inflammation  produced  by  swallowing  boiling  water  or  cor- 
rosive poisons,  especially  nitric  or  sulphuric  acid,  or  ammonia. 
The  symptoms  of  acute  cesophagitis  are  usually  mixed  up  with 
those  of  inflammation  of  the  pharynx,  or  of  the  stomach.  We 
may,  however,  infer  its  presence  if  difficulty  and  pain  in  degluti- 
tion exist  for  which  nothing  in  the  throat  accounts,  and  if  these 
phenomena  be  associated  with  hiccough  and  with  a  burning  sen- 
sation between  the  shoulders,  in  the  course  of  the  tube.  CEsoph- 
agitis  is  sometimes  encountered  in  infancy. f 

Of  the  chronic  diseases  of  the  oesophagus,  stricture  is  the  most 
common.  The  narrowing  may  take  place  at  any  part  of  the  tube, 
and  results  from  preceding  inflammation  or  ulceration,  from  can- 
cerous degeneration  of  the  walls,  or  from  the  pressure  of  a  tumor, 
of  an  abscess,  or  of  an  aneurism;  sometimes  it  is  congenital.  The 
formidable  malady  manifests  itself  by  impediment  in  swallowing : 
even  liquid  food  cannot  pass  without  great  difficulty ;  and  if  the 
stricture  go  on  increasing,  the  patient  perishes  miserably  by  star- 
vation. In  addition  to  the  obstruction  to  the  passage  of  food, 
we  may  find  a  peculiar  pain  occurring  at  a  particular  part  of  the 
<tube,  and  that  the  patient  raises,  without  cough  or  vomiting,  clots 
of  blood  presenting  the  same  shape. 

The  matter  ejected  in  the  attempts  at  deglutition  consists  simply 
of  masticated  food  toa-ether  with  more  or  less  mucus.     If  lona: 


*  See  an  elaborate  paper  on  the  subject  of  these  abscesses,  by  AUin,  New 
York  Journ.  of  Med.,  Nov.  1851;  also  Stephen  Smith,  Amer.  Journ.  Med. 
Sci.,  Oct.  1871;  Despres,  Gazette  des  Hopitaux,  No.  32,  1873;  H.  Glutton, 
Brit.  Med.  Journ.,  London,  1887,  i. ;  E.  F.  lugals,  Amer.  Journ.  Med.  Sci., 
Phila.,  1887,  N.  S.,  xcv.  ;  H.  Burckhardt,  Centralbl.  f.  Chir.,  Leipz. 

t  Brush,  New  York  Med.  Eec,  1883,  xxiii. 


478  MEDICAL   DIAGNOSIS. 

retained,  the  albuminous  materials  arc  macerated  or  putrid ;  the 
starchy  materials  are  in  process  of  fermentation ;  fungi  are  also 
formed  in  great  quantities,  although  never  sarcinpe.*  Should 
there  be  doubt  as  to  the  seat  of  the  obstruction,  a  bougie  will 
clear  np  the  doubt ;  and  thus  we  possess  in  this  instrument  the 
most  valuable  diagnostic  as  well  as  therapeutic  agent.  But  we 
must  not  immediately  conclude,  because  the  bougie  meets  with 
resistance,  that  an  organic  stricture  is  present.  The  narrowing 
may  be  only  spasmodic,  yet  give  rise  to  the  symptoms  of  organic 
constriction.  But  they  are  not  permanent :  at  times  nourishment 
is  readily  swallowed,  and  a  full-sized  bougie  passes  with  ease. 
Spasmodic  stricture  occasionally  accompanies  ulceration  of  the 
larynx ;  but  it  is  chiefly  met  with  iu  hypochondriacs  and  in  hys- 
terical women.  The  latter,  indeed,  sometimes  fancy  that  they  are 
incapable  of  swallowing,  and  reject  the  food  they  take  without 
there  being  even  a  temporary  spasm  to  prevent  its  passage.  Spas- 
modic stricture  is  also  an  attendant  on  cerebral  disease. 

The  distinction  of  the  other  causes  of  stricture  is  not  always 
an  easy  matter.  In  the  stenosis  arising  from  syphilis,  we  lay 
great  stress  on  the  history  and  on  the  results  of  an  antisyphilitic 
treatment.  In  the  strictures  due  to  compression,  we  discern  the 
swelling  that  has  occasioned  them,  and  the  oesophagus  is  apt  to  be 
pushed  to  one  side.  In  strictures  the  result  of  cicatrices,  we  have 
the  gradual  development  of  the  aifection  after  an  injury  or  the 
swallowing  of  some  irritant  poison,  and  the  great  resistance  of 
the  dense  tissues  to  the  sound  is  very  significant.  Cancerous  nar- 
rowing occurs  after  forty  years  of  age,  progresses  steadily,  and,  as 
Ziemssen  has  pointed  out,  is  frequently  associated  with  paralysis 
of  the  recurrent  laryngeal  nerves.  It  may  aifect  the  Avhole  middle 
part  of  the  oesophagus,  f 

Dilatation  of  the  oesophagus  above  the  seat  of  a  stricture,  or 
without  a  stricture  existing,  is,  on  the  whole,  a  rare  disease.  Its 
chief  symptoms,  when  extensive,  are  difficulty  in  swallowing, 
vomiting  or  regurgitation  of  food,  a  swelling  in  the  neck  coming 
on  after  eating  and  diminishing  greatly  after  vomiting  or  by 
pressure,  slowly-progressing  inanition,  and  at  times  long  sjiells 

■*  Ziemssen,  "Diseases  of  the  (Esophagus,"  in  Ziemssen's  Cyclopedia, 
f  Moore,  Lancet,  London,  1883,  i.  13. 


DISEASES    OF   THE    MOUTH,   PHARYNX,  ETC.  479 

of  delusive  improvement.  The  sound  may  penetrate  through  the 
ueck  of  the  sac  with  difficulty,  or  enter  it  readily,  which  largely 
depends  upon  whether  the  sac  be  empty  or  full ;  once  in  the  sac, 
the  end  of  the  tube  can  be  generally  moved  about  with  ease. 

In  all  the  diseases  mentioned,  the  value  of  the  sound  as  a 
means  of  diagnosis  has  been  spoken  of.  A  few  mcjre  remarks 
about  it  may  not  be  amiss.  When  the  sound  on  reaching  a  par- 
ticular spot  always  occasions  pain,  we  may  infer  the  existence  of 
inflammation  or  ulceration  at  this  point,  and,  in  the  case  of  ulcera- 
tion, some  pus  or  blood  is  likely  to  be  brought  up  on  the  instru- 
ment. Should  any  doubt  exist  whether  the  sound  have  passed 
into  the  oesophagus  or  into  the  larynx,  let  the  patient  be  directed 
to  speak  ;  he  can  make  no  noise  if  the  tube  be  in  the  larynx.  In 
cases  remaining  doubtful,  a  lighted  candle  may  be  placed  before 
the  end  of  the  tube  projecting  from  the  mouth.  If  the  instru- 
ment be  in  the  windpipe,  the  flame  will  be  wafted  to  and  fro 
with  the  currents  of  air  ;  if  in  the  oesophagus,  nothing  of  the  kind 
is  to  be  observed,  except  when  the  tube  is  in  the  intrathoracic 
portion. 

It  has  been  proposed  to  study  the  diseases  of  the  oesophagus  by 
means  of  auscultation,  listening  while  the  patient  sw^allows  food 
or  liquid ;  and  we  owe  to  Hamburger  an  elaborate  description 
of  the  sounds.*  In  health,  the  oesophageal  sound  is  extremely 
distinct,  but  of  very  short  duration.  We  should  distinguish  it 
from  the  pharyngeal  swallowing  sound,  which  is  generally  a  loud 
gurgle.  In  a  moderately  advanced  stage  of  stricture  of  the 
oesophagus,  a  noise  similar  to  emptying  a  bottle,  "clucking," 
"  gurgling,"  is  perceived  ;  while  in  cases  of  dilatation  we  are  apt 
to  meet  with  a  sound  like  that  heard  when  rain  driven  by  the 
wind  impinges  and  is  deflected.  In  cases  of  very  marked  stricture 
or  of  obstruction  by  an  impacted  foreign  body,  we  find  that  the 
act  of  deglutition  cannot  be  detected  below  a  certain  point,  while 
it  is  distinct  above.  To  auscult  the  oesophagus,  we  should  place 
the  stethoscope  in  the  vicinity  of  the  hyoid  bone,  also  to  the  left 
of  the  vertebral  column  from  the  upper  dorsal  vertebra  dow^nward. 

*  Jahrbiiclier  der  k.  k.  Gesellschaft  der  Aerzte  in  "Wien,  Bd.  xviii.  See, 
also,  Oppolzer's  Lectures ;  Morell  Mackenzie,  London  Lancet,  May,  1874 ; 
Allbutt,  Brit.  Med.  Journ.,  Oct.  1875  ;  Gaston  Sainte-Marie,  Des  differentes 
modes  d'exploration  de  I'cesophage,  Paris,  1875. 


480  MEDICAL   DIAGNOSIS. 

This  mclhod  of  exploration  has  not,  however,  proved  itself  of 
nuieh  value. 

The  disorders  of  the  pharynx  and  (esophagus  have  as  a  common 
symptom  difficulty  in  swallowing.  But  Ave  must  not  forget  that 
other  causes  may  produce  (li/sphagia,  such  as  paralysis  of  the  nuis- 
cles  of  the  throat,  diseases  of  the  larynx  or  trachea,  particularly 
ulcerative  diseases,  and  aueurismal  tumors  within  the  chest. 


CHAPTER    VI. 

DISEASES   OF   THE   ABDOMEN. 

The  abdominal  cavity  contains  viscera  of  very  varied  func- 
tions :  some  form,  others  break  down  organic  constituents ;  while 
others,  again,  excrete  the  broken-down  material.  They  all,  how- 
ever, labor  in  one  cause ;  they  all  work  toward  preserving  a  nor- 
mal state  of  the  blood,  either  by  preparing  fit  matter  for  it  or 
by  removing  such  substances  as  would  be  hurtful  if  they  were 
retained.  Any  serious  derangement  of  any  of  these  viscera, 
especially  any  serious  chronic  derangement  of  those  which  are 
not  simply  reservoirs,  must  therefore  lead  to  a  deterioration  of 
the  blood  and  to  a  defective  nourishment  of  the  body.  But,  in- 
dependently of  the  change  in  the  blood  and  the  falling  off  in  the 
general  nutrition,  there  are  no  vital  symptoms  which  characterize 
abdominal  diseases  as  a  group ;  and,  as  many  causes  may  give 
rise  to  the  same  symptoms,  they  furnish  but  little  information  as 
to  the  particular  organ  at  fault.  This  we  learn  to  some  extent 
by  examining,  where  it  can  be  done,  the  secretions  or  excretions ; 
to  some  extent  by  noticing  the  peculiar  appearances  of  the  skin 
which  are  produced  by  alteration  of  the  blood;  and  by  the  ex- 
ploration of  the  organs  through  the  parietes  of  the  abdomen.  It 
is,  in  truth,  by  means  of  the  physical  method  of  investigation  that 
we  often  obtain  the  most  valuable  information  not  only  as  to  the 
seat  but  even  as  to  the  nature  of  the  morbid  action ;  and,  although 
physical  exploration  of  the  abdomen  does  not  yield  as  perfect  re- 
sults as  when  this  form  of  diagnosis  is  aj)plied  to  the  affections  of 
the  thorax,  the  senses  of  sight  and  touch  still  supply  us  with  an 
amount  of  knowledge  most  valuable,  and  with  which  it  would  be 
difficult  to  dispense.  I  speak  only  of  the  senses  of  sight  and  touch, 
because  the  sense  of  hearing,  save  in  so  far  as  it  enables  us  to 
judge  of  the  sounds  elicited  by  percussion,  or  of  murmurs  in 
the  vessels,  is  not  very  applicable  to  the  study  of  diseases  below 

31  481 


482  MEDICAL    DIAGNOSIS. 

the  tliapliragm.     Let  us  pass  in  review  the  different  methods  of 
physical  diai>nosis  with  reference  to  abdominal  disorders. 

Methods  and  General  Results  of  Physical  Examination 
of  the  Abdomen. 

INSPECTION. 

By  inspection  we  learn  the  size,  shape,  form,  and  movements 
of  the  abdomen.  To  inspect  the  abdomen  satisfactorily,  the 
patient  should  be  placed  in  an  easy  attitude,  either  standing  or 
sitting.  The  recumbent  position  is  less  eligible,  though  we  are 
often  obliged  to  examine  sick  persons  in  this  posture.  Whenever 
practicable,  ocular  inspection  must  be  made  not  only  from  the 
front,  but  also  from  the  sides  and  from  the  back.  In  appre- 
ciating the  results  thus  obtained,  it  is  necessary  to  bear  in  mind 
that  the  appearance  of  the  abdominal  walls  is  modified  by  certain 
physiological  conditions.  The  abdomen  is  much  larger,  in  com- 
parison to  the  size  of  the  chest,  in  childhood  than  in  adult  age. 
It  is  more  voluminous  in  females,  especially  such  as  have  given 
birth  to  children.  It  increases  in  size  with  advancing  years,  par- 
ticularly when  a  tendency  to  obesity  exists.  Its  shape  is  some- 
what altered  by  the  pernicious  habit  of  wearing  tight  stays.  Its 
upper  portion  is  distended  after  a  copious  meal. 

In  disease  we  may  observe  either  partial  or  general  abdominal 
enlargement  The  latter  is  caused  by  accumulations  of  air  in  the 
intestinal  canal ;  by  liquid  in  the  peritoneum ;  by  an  oedematous 
condition  of  the  abdominal  walls ;  or  by  large  tumors  which  fill 
up  the  whole  cavity.  A  partial  enlargement  is  mainly  produced 
by  an  increase  in  size  of  particular  organs.  It  may  also  be 
brought  about  by  swelling  of  the  mesenteric  glands,  or  by  tumor, 
— solid  or  hernial ;  and  it  is  sometimes  due  to  diseases  above  the 
diaphmgm.  A  pleuritic  or  a  pericardial  effusion,  or  emphysema 
of  the  lungs,  may  give  rise  to  a  marked  fulness  belo\\-  the  margin 
of  the  ribs. 

A  retraction  of  the  abdominal  parietes  is  perceived  in  general 
emaciation,  and  is  very  obvious  in  that  dependent  upon  a  nar- 
rowing of  the  cardiac  or  the  pyloric  orifice  of  the  stomach,  or 
upon  chronic  diarrhoea  or  dysentery.  It  is  also  noticed  in  lead 
colic  and  in  cephalic  diseases,  especially  in  tubercular  meningitis. 


DISEASES   OF   THE   ABDOMEN.  483 

There  are  further  changes  in  the  appearance  of  certain  external 
parts  which  tend  to  ekicidate  the  state  of  the  parts  witliin.  Thus, 
we  learn  from  the  distention  of  the  superficial  veins  that  an  olj- 
struction  to  the  flow  of  blood  exists  in  the  large  veins  of  the 
abdomen,  either  in  the  portal  system  or  in  the  vena  cava.  The 
lessening  of  the  depression  at  the  umbilicus,  unless  it  be  produced 
by  pressure  limited  to  the  spot  where  the  umbilicus  lies,  is  a  sign 
indicative  of  general  abdominal  enlargement. 

While  inspecting  the  abdomen,  we  may  see  distinct  movements. 
The  act  of  breathing  gives  rise  to  a  motion  which  is  very  slight 
when  a  tumor  or  any  other  impediment  interferes  with  the  free 
action  of  the  diaphragm,  and  which  is  much  exaggerated  by  dis- 
eases within  the  thoracic  cavity.  The  rolling  of  the  intestines 
is  sometimes  visible  on  the  exterior ;  so  are  at  times  those  shift- 
ings  of  accumulations  of  gas  which  give  rise  to  a  series  of  jerking 
elevations ;  so,  too,  are  occasionally  the  spasmodic  contractions 
and  relaxations  of  the  abdominal  muscles.  But  none  of  these  is 
as  frequently  encountered  as  a  pulsation  in  the  epigastric  region, 
which  is  often  mistaken  for  an  aneurism. 

PALPATION. 

We  judge  by  the  application  of  the  hand  of  the  size,  position, 
and  consistence  of  the  viscera  which  are  felt  through  the  abdom- 
inal walls.  We  determine  whether  the  parts  are  firmly  attached 
or  movable ;  whether  they  are  smooth  or  nodulated ;  whether 
they  possess  a  motion  of  their  own;  whether  they  are  tender; 
and  by  tapping  with  the  fingers  of  one  hand,  while  those  of  the 
other  are  applied  to  another  portion  of  the  surface,  we  discover, 
by  the  peculiar  feeling  of  fluctuation,  the  presence  of  fluid  in 
the  abdominal  cavity.  We  satisfy  ourselves  further,  by  the  sense 
of  touch,  of  the  state  of  the  parietes,  whether  resistant  or  elastic, 
oedematous  or  not ;  and  we  may  detect  a  friction  fremitus. 

In  order  to  use  palpation  with  most  effect,  the  abdominal  miis- 
.cles  must  be  relaxed  ;  and  to  do  this  the  patient  should  be  placed 
on  his  back,  and  the  thighs  be  flexed  on  the  body.  Occasionally 
it  is  essential  to  vary  this  position ;  to  turn  him  from  side  to  side, 
or  to  examine  him  when  erect.  The  amount  of  pressure,  too, 
should  not  always  be  the  same.  When  we  wish  to  examine  deep 
parts,  the  pressure  is  increased.     The  character  and  the  intensity 


484  MEDICAL   DIAGNOSIS. 

ot"  tlie  pain  wliicli  pressure  calls  forth  ol'ten  throw  considerable 
light  on  the  disease  we  are  investigating.  Thus,  if  it  take  deep 
pressure  to  produce  pain,  we  are  usually  right  in  concluding  that 
the  mischief  is  not  superficially  seated.  The  pain  of  inflamma- 
tion of  the  serous  membrane  is  commonly  much  augmented  by 
pressure,  and  is  of  a  very  severe,  cutting  character.  Pain  due  to 
inflammation  of  any  part  of  the  mucous  membrane  of  the  intes- 
tinal tract  is  duller.  All  neuralgic  or  nervous  i)ain,  such  as  that 
of  colic,  is,  as  a  rule,  relieved  rather  than  augmented  by  pressure, 
and  may  thus  be  distinguished  from  the  tenderness  caused  by 
inflammation. 

But  we  shall  not  enter  into  any  fuller  particulars  as  to  what  jial- 
pation  teaches  us  in  individual  diseases  of  the  abdomen ;  because, 
as  there  is  hardly  one  of  any  importance  in  which  it  is  not  of 
some  service,  we  should  say  here  what  it  would  be  necessary  to 
dwell  on  repeatedly  hereafter.  There  is,  however,  one  point  con- 
nected with  the  subject  which  may  be  briefly  mentioned, — the 
attempt  to  use  palpation  as  a  means  of  diagnosis  by  the  introduc- 
tion of  the  hand  into  the  rectum.  This  method  has  been  recom- 
mended by  Simon,  and  it  is  asserted  that  the  hand  can  be  passed 
far  enough  to  detect  even  calculi  lodged  in  the  kidney.  But  the 
method  is  both  disagreeable  and  not  free  from  danger.  Dilata- 
tion of  the  sphincter  should  be  gradual,  five  minutes  at  least 
being  allowed  for  its  accomplishment.  And,  with  all  precautions, 
the  information  obtained  may  be  indecisive.  Strictures  high  up 
in  the  rectum  or  in  the  sigmoid  flexure  of  the  colon  may  be  read- 
ily discerned,  but  a  stricture  below  the  descending  colon  may  exist 
although  the  hand  be  unable  to  discover  it. 

PEKCUSSION. 

Percussion  is,  in  the  study  of  abdominal  affections,  even  more 
valuable  than  palpation.  By  it  we  can  circumscribe  the  different 
organs  with  accuracy  ;  we  can  judge  of  the  position  of  the  stomach 
and  intestines;  we  can  limit  tlie  distended  bladder,  and  fix  the 
borders  of  the  liver  and  spleen.  By  its  aid,  further,  we  can  tell 
whether  a  distention  of  the  abdomen  is  produced  by  air,  or  by  a 
solid  tumor,  or  by  liquid.  But,  without  entering  here  into  any 
particulars  as  to  its  use  in  individual  disorders,  we  may  examine 
the  results  it  yields  when  applied  to  the  healthy  abdomen. 


DISEASES   OF   THE   ABDOMEN.  485 

To  render  percussion  a  trustworthy  interpreter  of  the  state  of 
the  abdominal  viscera,  the  patient  should  be  placed  in  the  same 
position  as  for  palpation.  The  sounds  are  best  elicited  by  mediate 
percussion.  But,  to  appreciate  them  fully,  something  more  is 
requisite  than  to  produce  a  distinct  sound  and  to  be  able  to  tell 
whether  it  is  dull  or  tympanitic.  We  must  be  acquainted  with 
the  relations  of  the  parts  which  the  abdominal  walls  conceal  from 
view,  and  take  into  account  that  during  the  digestive  process  the 
contents  and  position  of  these  organs  may  vary  sufficiently  to 
modify  the  percussion  sound. 

To  begin  with  the  airless  viscera.  The  liver  is  one  of  the  easiest 
organs  to  limit.  We  determine  its  upper  boundary  by  striking 
with  moderate  force  in  a  line  from  somewhat  above  the  rig-ht 
nipple  toward  the  lower  part  of  the  thorax,  until  marked  resist- 
ance and  dulness  tell  us  that  a  solid  organ  has  been  reached.  At 
this  point  we  make  a  mark;  then  we  again  percuss  downward 
from  near  the  median  line,  and  above  the  dulness  just  obtained ; 
then  we  percuss  from  the  axilla  downward ;  then  posteriorly  from 
beneath  the  lower  angle  of  the  scapula ;  and  so  on,  until  the  line 
traced  out  reaches  the  vertebral  column. 

The  dulness  thus  elicited  marks  the  upper  boundary  of  the 
liver ;  at  least  of  the  portion  more  directly  in  contact  with  the  ab- 
dominal walls.  Anteriorly  it  extends  from  the  lower  extremity 
of  the  sternum  to  between  the  fifth  and  sixth  ribs;  at  the  side, 
the  dulness  is  generally  in  the  seventh  intercostal  space ;  near 
the  vertebral  column,  it  is  on  a  level  with  the  tenth  or  the 
eleventh,  more  rarely  with  the  ninth,  interspace.  The  dulness 
of  the  left  lobe  reaches  nearly  two  inches  across  the  median  line ; 
but  the  heart  lies  here  so  near  to  the  liver  that  w^e  cannot  with 
accuracy  distinguish  the  flat  sound  of  the  one  from  the  flat  sound 
of  the  other ;  nor  indeed  is  this,  for  practical  purposes,  of  great 
consequence. 

After  the  upper  border  has  been  fairly  traced  out  anteriorly, 
laterally,  and,  if  thought  necessary,  posteriorly,  we  determine  the 
inferior  margin  of  the  organ.  This  is  readily  effected  by  per- 
cussing downward  from  the  already-ascertained  line  of  dulness, 
and  noting  where  the  large  intestine  sends  forth  its  distinct  ts^m- 
panitic  sound.  To  determine  the  lower  border  correctly,  the  plex- 
i meter  must  be  pressed  firmly  on  the  integuments,  and  the  stroke 


486  MEDICAL   DIAGNOSIS. 

of  the  finger  be  slight ;  for  if  it  be  strong,  we  obtain  the  sound 
of  the  surrounding  hoHow  viscera  through  the  thin  layer  of  liver 
which  covers  them,  and  before  we  have  arrived  at  its  margin. 
This  mode  of  procedure  is  different  from  the  one  pursued  to  de- 
termine the  height  to  which  the  liver  rises,  because  the  position  of 
the  parts  is  different.  Superiorly,  the  lung  descends  between  the 
surface  and  that  portion  of  the  convex  surface  of  the  liver  which 
fits  into  the  diaphragm,  and  it  requires  strong  percussion  to  bring 
out  the  dulness  of  the  deep-seated  solid  organ.  By  forcible  per- 
cussion, however,  we  detect  a  decided  loss  of  the  pulmonary  reso- 
nance at  about  the  fourth  intercostal  space. 

The  inferior  border  of  the  liver  will,  anteriorly,  be  generally 
found  to  lie  immediately  at,  or  to  project  below,  tlie  last  rib ;  jios- 
teriorly,  we  cannot  determine  this  border  positively,  for  it  becomes 
continuous  with  the  dulness  occasioned  l)y  the  right  kidney.  The 
lower  margin  of  the  left  lobe  is  commonly  met  with  at  the  upper 
third  of  a  line  drawn  from  the  ensiform  cartilage  to  the  umbilicus. 
A  distended  gall-bladder  may  cause  a  strictly-defined  dulness  lower 
than  the  dulness  of  the  surrounding  liver. 

The  spleen  is  not  so  easily  circumscribed  as  the  liver.  Indeed, 
if  the  stomach  or  the  intestines  be  distended,  it  is  difficult  to  detect 
the  dull  sound  of  the  spleen.  To  find  its  limits,  we  must  place  the 
patient  on  his  right  side,  with  his  legs  flexed ;  or  let  him  stand  erect, 
and  then  begin  to  strike  with  some  force  in  a  line  from  the  axilla 
to  the  crest  of  the  ilium.  At  the  ninth,  or  sometimes  at  the  tenth, 
rib,  the  sound  becomes  dull,  and  there  is  much  greater  resistance 
to  the  finger.  Here  is  the  upper  boundary  of  the  spleen.  We  mark 
the  spot,  and  continue  to  percuss  in  the  same  line  until,  at  about 
the  twelfth  rib,  we  arrive  at  the  lower  boundary  of  the  organ,  as 
indicated  by  the  distinct  tympanitic  sound  of  the  intestines. 

After  the  vertical  diameter  has  been  thus  ascertained,  the  hori- 
zontal is  readily  determined  by  percussing  from  the  median  line 
to  a  point  between  the  lines  which  trace  the  superior  and  inferior 
margins,  and  by  noticing  where  the  sound  of  the  stomach  gives 
wav  to  the  dull  sound  of  the  solid  viscus.  When  these  three 
points  have  been  decided  upon,  we  have  learned  enough  for  prac- 
tical purjioses.  We  may  then,  if  we  choose,  percuss  posteriorly ; 
but  we  cannot  circumscribe  the  spleen  Avith  any  accuracy  behind, 
because  its  dulness  becomes  continuous  with  that  of  the  left  kidney. 


DISEASES   OF   THE   ABDOMEN.  487 

The  average  size  of  the  spleen  is  four  inches  in  length  and  three 
in  width  ;  but  it  may  in  a  diseased  state  increase  to  twice  or  three 
times  that  size.  When  the  viscus  eludes  detection  by  percussion, 
we  may  infer  it  to  be  small ;  provided  the  stomach  and  intestines 
be  not  much  distended  with  gas. 

The  Jddneys  cannot  be  limited  with  anything  like  accuracy,  ex- 
cept at  their  inferior  and  outer  borders,  where  the  dull  sound  they 
occasion  is  surrounded  by  the  intestinal  resonance.  This  dulness 
extends  somewhat  lower  during  a  full  inspiration. 

To  set  limits  to  the  stomach  and  intestines,  by  means  of  percus- 
sion, requires  an  ear  accustomed  to  discriminate  between  shades  of 
sound,  since  we  have  to  judge  more  between  sounds  of  different 
degree,  but  similar  to  one  another,  than  between  sounds  of  different 
character.  JSTor  are  the  tones  elicited  always  the  same  over  the 
same  spot ;  they  vary  as  the  contents  of  the  hollow  viscera  vary. 
We  can  make  use  of  this  circumstance  for  purposes  of  diagnosis. 

The  stomach,  when  not  unusually  distended  with  gas  or  with 
food,  renders  a  sound  which  is  hollow,  ringing,  and  tympanitic  to 
a  certain  degree,  yet  which  is  not  tympanitic  as  that  of  the  intes- 
tine is.  It  is,  in  fact,  a  sound  unlike  any  other,  and  experience 
soon  enables  us  to  distinguish  it  from  that  of  the  surrounding 
viscera.  Sometimes  the  sound  is  distinctly  amphoric.  To  deter- 
mine the  boundaries  of  the  stomach,  it  is  necessary  to  mark  out 
first  the  lower  margin  of  the  liver,  for  it  covers  a  portion  of  the 
stomach  ;  then  the  heart  and  the  inner  border  of  the  spleen.  The 
part  which  lies  between  these  solid  viscera  yields  the  sound  of  the 
stomach,  mixed  at  one  point,  namely,  to  the  left  of  the  apex  of 
the  heart,  with  the  resonance  of  the  lung.  Near  this  spot,  about 
opposite  to  the  seventh  rib,  the  cardiac  extremity  of  the  stomach 
is  situated ;  below  it  is  the  body  of  the  organ.  To  ascertain  its 
lower  border,  we  percuss  gently  in  a  downward  direction,  until 
the  alteration  in  sound  shows  that  we  are  striking  over  the  colon. 
The  difference  is  at  times  very  obvious,  at  times  very  slight.  It 
is  readily  detected  if  the  stomach  contain  either  solid  or  liquid 
ingesta.  Availing  ourselves  of  this  fact,  we  may  sometimes,  with 
advantage,  let  the  patient  swallow  a  glass  of  water.  By  placing 
him  in  the  erect  position,  the  fluid  gravitates  to  the  greater  cur- 
vature, and  the  line  of  comparative  dulness  indicates  the  lower 
margin  of  the  stomach,  which  is  generally  found  near  but  above 


488 


MEDICAL   DIAGNOSIS. 


the  umbilicus.  In  men  the  lower  border  of  the  stomach  is  a  little 
higher  than  in  women  ;  in  working-women  it  is  higher  than  in 
other  women  ;  in  children  under  fifteen  years  of  age  it  very  rarely 
extends  to  the  umbilicus ;  in  persons  of  fifty  it  is  not  unusual  for 


Fig.  41. 


Results  of  abdominal  percussion,  as  set  forth  in  the  text.  The  dark  shades  indi- 
cate marked  dulness;  the  light  shading  exhibits  a  lessening  of  the  clear  or  of  the 
tympanitic  character  of  the  sound, — an  approach  to  dulnes.s. 

it  to  do  so.     In  strong,  healthy  people  the  whole  position  of  the 
stomach  is  more  horizontal  than  in  weak  ones.* 

Another  method  to  determine  the  limits  of  the  organ,  as  Avell  as 
whether  or  not  the  pylorus  is  capable  still  of  self-closure  in  the 
direction  of  the  duodenum,  or  is  permanently  patent,  has  been 
jjroposed  by  Epstein. f     It  consists  in  the  distention  of  the  stomach 


*  Obrastzow,  Deutsches  Arch.  f.  Klin.  Med.,  Bd.  xliii.,  1888. 
t  Klinische  Vortrage,  No.  155,  1878. 


DISEASES   OF   THE   ABDOMEN.  489 

by  means  of  carbonic  acid,  generated  by  first  letting  the  patient 
swallow  tartaric  acid  dissolved  in  lukewarm  water  and  then  rather 
more  bicarbonate  of  sodium,  about  a  full  teaspoonful.  The 
stomach  Ijecomes  very  much  distended,  and  emits  a  deep  tym- 
panitic note  on  percussion,  unlils;e  that  over  the  intestines;  but 
if  the  pylorus  be  incapable  of  closure,  the  intestines  too  become 
swollen,  and  their  tympanitic  note  is  changed. 

The  colon  yields,  in  all  its  parts,  a  sound  of  a  purer  tympanitic 
character  than  the  stomach,  the  note  of  which  is,  indeed,  in  many 
respects  more  amphoric  than  tympanitic.  When  the  tube  contains 
faeces,  the  sound  is  modified  ;  and  as  these  are  prone  to  accumulate 
on  the  left  side  in  the  descending  colon,  and  especially  where  this 
passes  into  the  iliac  fossa,  it  is  usually  not  so  resonant  as  the 
ascending  colon.  The  small  intestines,  unless  they  are  filled  with 
fluid  or  solids,  or  distended  with  gas,  render  a  sound  of  higher 
pitch  and  of  smaller  volume  than  the  surrounding  large  intestine, 
and  by  the  less  deep-toned  sound  their  position  may  be  accurately 
determined.  Artificial  distention  of  the  colon,  by  generating  car- 
bonic acid  in  it  by  means  the  same  as  just  mentioned  passed  into 
the  lower  bowel,  has  been  advocated  for  diagnostic  purposes  by 
Ziemssen.*  It  enables  us  to  distinguish  with  ease  the  outline  of 
the  large  intestine,  and  shows  whether  there  is  communication 
with  adjacent  organs,  such  as  the  stomach,  the  bladder,  or  the 
small  intestine. 

The  position  of  the  viscera  in  the  pelvis  cannot  be  ascertained 
by  means  of  percussion.  It  is  only  when  the  bladder  is  much 
distended,  or  the  uterus  augmented  in  size,  that  the  outline  of 
either  can  be  traced  on  the  walls  of  the  abdomen. 

AUSCULTATION. 

Auscultation  is  serviceable  in  aiding  in  the  detection  of  an 
abdominal  aneurism  ;  and  sometimes  an  enlarged  spleen  gives  rise 
to  a  distinct  blowing  murmur ;  or  the  rubbing  of  a  roughened 
peritoneum  may  occasion  a  friction  sound  ;  but,  on  the  whole,  the 
application  of  the  stethoscope  to  the  abdominal  walls  is  rarely  of 
much  aid.  In  health,  no  constant  sound  is  heard  save  that  of 
the  aorta  ;  for  the  rush  of  blood  through  the  other  arteries,  or 

*  Deutsches  Arch.  f.  Klin.  Med.,  Bd.  xxxiii.,  June,  1883. 


490  MEDICAL    DIAGXOSIS. 

through  the  veins,  produces  no  appreciable  murmur.  Wlicn  the 
stoiiiacli  is  distended  with  air  and  contains  liquid,  sounds  ])ossessing 
a  metallic  character  arc  perceived,  which  an  inexperienced  observer 
is  apt  to  consider  as  originating  in  the  lungs;  over  which,  in  truth, 
they  are  often  audible.  The  passage  of  gas  through  the  intestines 
gives  rise  to  those  peculiar  noises  termed  "borborvgmi."  In  the 
pregnant  state,  auscultation  is  of  value  in  detecting  the  pulsations 
of  the  foetal  heart  and  the  utero-placental  murmur. 


SECTION   I. 

DISEASES    OF    THE    STOMACH. 

As  the  disorders  of  the  stomach  are  so  common,  and  as  a  patient 
hardly  ever  gives  a  history  of  his  ailment  without  thinking  it 
obligatory  to  enter  into  a  minute  account  of  the  state  of  his  di- 
gestion, it  would  be  reasonable  to  suppose  that  no  affections  are 
so  well  understood  and  so  susceptible  of  clear  description  as  those 
of  this  viscus.  But  in  point  of  fact  there  are  none  so  little  un- 
derstood ;  indeed,  it  is  only  within  the  last  few  years  that  any 
attempts  have  been  made  to  penetrate,  with  the  light  thrown  by 
modern  means  of  research,  the  darkness  which  surrounds  the 
pathology  of  one  of  the  most  important  organs  in  the  body.  Most 
of  these  attempts  have  had  as  their  goal  to  ascertain  the  exact 
anatomical  changes  and  the  modifications  in  the  secretions,  which 
give  rise  to  the  symptoms  commonly  referred  to  perverted  func- 
tion ;  and  to  a  certain  degree  they  have  been  successful. 

The  stomach  is  examined  partly  by  physical  exploration  by  the 
methods  just  detailed,  and  partly  by  paying  attention  to  the  chem- 
ical changes  which  attend  the  digestive  acts.  The  accurate  study 
of  these  changes  is  leading  to  great  advances  in  the  investigation 
of  gastric  affections,  as  has  been  proved  especially  by  the  labors 
of  Leube*  and  of  Ewald.t  We  get  the  contents  of  the  stomach 
for  examination  seven  hours  after  a  full  or  "  trial  meal,"  given  as 

*  Deutsches  Arch.  f.  Klin.  Med.,  Bd.  xxxiii.,  1883  ;  ulso  Schreiber,  ib. 
f  Klinik  der  Verdauungskrankheiten,  Berlin,  1889. 


DISEASES   OF   THE   STOMACH.  491 

a  mid-day  dinner,  of  which  then,  if  the  act  of  digestion  have 
been  normally  carried  on  and  the  chyme  have  passed  on  into  the 
small  intestine,  nothing  remains  but  a  clear  liquid.  This  is  ob- 
tained by  the  introduction  of  a  soft  sound,  like  a  Nekton's  cathe- 
ter, which  also  can  be  used  for  examining  the  walls  and  orifices  for 
diagnostic  purposes.  The  liquid  flows  through  the  soft  sound  by 
pressing  on  the  epigastrium,  or  a  little  warm  water  may  be  first 
injected  into  the  stomach,  in  the  same  manner  as  is  done  in  washing 
out  the  viscus.  If  the  liquid  be  not  clear,  but  full  of  half-digested 
food,  we  know  at  once  that  the  stomach  is  not  performing  its  func- 
tion properly.  Ewald  has  recently  substituted  a  light  breakfast 
trial  meal,  a  small  amount  of  dry  bread  or  of  toast,  and  a  third  of  a 
litre  (about  eleven  fluidounces)  of  warm  water  or  weak  tea,  which, 
given  on  an  empty  stomach,  allows  the  gastric  contents  to  be  tested 
in  an  hour,  a  matter  often  of  great  convenience.  The  results  of 
these  trial  meals  should  be  filtered  for  accurate  examination. 

The  next  point  to  determine  is  the  composition  of  the  gastric 
juice  and  its  digestive  power.  We  first  have  to  ascertain  if 
the  liquid  obtained  be  acid,  how  acid  it  is,  and  what  its  acid 
nature  is  owing  to.  In  from  ten  to  fifteen  minutes  after  the  trial 
breakfast  acid  salts  and  a  free  acid  are  found ;  the  free  acid  is  lac- 
tic acid.  This  disappears  within  the  hour,  hydrochloric  acid 
gradually  taking  its  place,  and  at  the  end  of  an  hour  only  hydro- 
chloric acid  is  found  in  the  normal  stomach  contents.*  In  the 
ordinary  full  mid-day  trial  meal,  hydrochloric  acid  is  not  likely  to 
be  found  for  an  hour  or  two  after  the  ingestion.  It  is  true  that 
the  acid  phosphates  in  the  ingesta  determine  somewhat  the  acid 
character  of  the  gastric  juice,  but  the  hydrochloric  acid  is  alone, 
for  practical  purposes,  of  importance.  To  ascertain  the  presence 
of  hydrochloric  acid  methyl-violet  may  be  employed,  which  is 
turned  into  a  deep  blue  by  the  acid ;  or  tropeoline,  which  in  a 
saturated  watery  solution  is  a  dark  yellowish-red  liquid  that  on 
contact  with  any  free  acid  becomes  dark  brown,  while  with  acid 
salts  it  assumes  a  straw-colored  tint.  The  solution  of  phenic 
perchloride  of  iron  is  changed  by  hydrochloric  acid  from  a  steel 
blue  into  a  steel  gray,  whereas  organic  acids,  such  as  butyric  acid 
and  other  acids  of  decomposition,  turn  it  yellow.      Giinzburg's 

*  Ewald,  op.  cit.,  p.  21. 


492  MEDICAL  DIAGNOSIS. 

vanilline  solution  is  now  also  niiich  employed.  It  consists  of  two 
oi-amnies  of  })hloroglueine  and  one  gnunme  of  vanilline,  with 
tiiirty  grammes  of  absolute  aleohol.  A  few  drops  of  this  solution, 
which  is  of  a  yellowish  color,  added  to  the  liquid  containing  a 
mineral  acid,  such  as  hydroeliloric,  turns  it  at  once  a  bright-red 
hue ;  while  the  reagent  remains  unchanged  by  organic  acids,  such 
as  lactic  or  'acetic  acid.  The  Congo  red  paper,  as  proposed  by 
Riegel,  is  a  very  delicate  and  convenient  reagent.  Hydrochloric 
acid  gives  it  a  greenish-blue  color. 

The  extent  of  acidity  of  the  gastric  juice  is  more  difficult  to 
determine  than  the  presence  of  the  acids.  E\\  aid  recommends,  as 
a  ready  way,  to  triturate  with  one-tenth  of  normal  sodium  solution, 
ascertaining  the  saturation  point  with  litmus  paper  or  with  phe- 
nolphtaline.  Wolff*  puts  1  c.c.  of  the  filtered  gastric  juice  in  a 
graduated  cylinder,  and  dilutes  it  repeatedly  until  there  is  no  more 
reaction  ^^■ith  the  standard  methyl-violet  solution.  We  may  test 
the  solving  power  of  the  gastric  juice  by  taking  a  i)iece  of  hard- 
boiled  egg  albumen  and  adding  the  gastric  juice  in  a  test-tube. 
Heated  in  a  culture  oven,  the  egg  albumen,  if  the  gastric  juice  be 
normal,  is  dissolved  in  about  an  hour.  Propeptone  and  peptone 
are  determined  by  the  Biuret  reaction. 

The  symptoms  which  are  constantly  met  with  in  derangements 
of  the  stomach,  whether  organic  or  functional,  are  loss  of  appetite, 
nausea  and  vomiting,  acidity,  flatulency,  and  pain. 

Loss  of  Appetite. — This  manifests  itself  in  various  ways.  It 
may  amount  to  absolute  repugnance  to  taking  any  kind  of  food,  or 
may  be  merely  an  inability  to  partake  of  certain  articles.  Again, 
little  by  little  the  process  of  digestion  may  become  more  and  more 
difficult  and  annoying,  and  the  patient  in  consequence  instinctively 
abstains  from  eating.  What  the  loss  of  appetite  depends  on,  we 
do  not  know.  That  nervous  influence  has  something  to  do  with 
the  anorexia,  is  shown  by  the  sudden  deprivation  of  all  desire  to 
eat  when  any  strong  impression  is  made  on  the  nervous  system, — 
such  as  that  caused  by  the  unexpected  receipt  of  unwelcome  news. 
The  collection  of  epithelium  on  the  mucous  membrane  is  also  con- 
nected with  a  marked  diminution  of  the  appetite ;  for  with  a  tongue 
much  coated,  absolute  disgust  at  the  mere  thought  of  taking  food 


*  Transact,  of  the  Phila.  Co.  Med.  Soc,  Oct.  1889. 


DISEASES    OF    THE    STOMACH.  493 

often  exists,  which  yields  to  relish  fijr  food  as  soon  as  the  tongue 
beffins  to  clean. 

Attending  lost  apj)etite,  we  meet  sometimes  with  great  emacia- 
tion and  with  signs  as  if  even  the  small  quantity  of  food  taken 
were  not  absorbed  into,  or  utterly  failed  to  nourish,  the  system. 
There  is  apt  to  be  sensitiveness  over  the  abdomen,  and  spots  of 
particular  sensitiveness  exist  which  correspond  to  the  situation  of 
the  mesenteric  glands.  We  find,  however,  no  evidence  of  organic 
disease,  either  in  the  abdomen  or  in  the  lungs ;  nor  does  this 
pseudo  tabes  mesenterica,  if  I  may  so  call  it,  occur,  like  the  dis- 
ease it  simulates,  in  scrofulous  or  tubercular  patients.  I  have 
met  with  a  number  of  cases,  chiefly  in  young  women  with  low- 
ered vital  force,  fond  of  excitement,  and  living  indolent  lives. 
Some  were  hysterical,  others  not.  But  in  all  the  complaint 
seemed  to  be  due  to  deficient  nerve- power,  with  impaired  func- 
tion of  the  stomach,  and  very  possibly  of  the  abdominal  glands. 
This  disorder  is  probably  the  same  as  that  described  by  Gull  as 
hysteric  apepsia,*  and  kindred  to  the  affection  delineated  by 
Lasegue  as  hysteric  anorexia. f 

Instead  of  the  appetite  being  lost,  it  may  be  capricious,  or  even 
ravenous.  A  craving  after  food  is  not  often  combined  with  a 
structural  lesion.  Yet  we  occasionally  meet  with  it  in  persons 
aifected  with  gastric  ulcer.  It  is  common  to  find  it  in  those  who 
suffer  from  neuralgia  of  the  stomach.  And  sometimes  in  cases 
of  mere  nervous  gastric  disturbance,  with  or  without  pain,  there 
is  an  extraordinary  exaggeration  of  the  appetite  :  the  patient  eats 
largely  eight  or  even  fifteen  times  a  day,  digests  his  food,  yet  is 
constantly  hungry. | 

The  feeling  of  thirst  does  not  lessen  when  tlie  desire  for  food  does. 
On  the  contrary,  it  usually  increases  when  the  latter  diminishes. 

Excessive  Acidity  of  the  Stomach. — Excessive  acidity 
occurs  from  various  causes.  The  gastric  juice  may  be  secreted  in 
great  quantities,  or  it  may  contain  an  abnormal  amount  of  acid. 
But  excessive  acidity  is  far  more  frequently  due  to  the  decom- 
position of  food  and  to  a  process  of  fermentation  dependent  rather 


*  Transactions  of  the  Clinical  Society,  vol.  vii.,  1874. 

f  Arch.  Gen.  de  Med.,  April,  1873. 

:j:  Cases  recorded  by  Guipon,  Bulimic  and  Syncopal  Dyspepsia. 


494  MEDICAL    DIAGNOSIS. 

upon  an  insiiffieient  amount  of  the  gastric  solvent  than  upon  its 
superfluity.  It  then  manifests  itself  only  after  meals.  "\Mien  tlie 
mueous  membrane  is  eovered  with  a  tenaeious  mucus  or  with  thick 
layers  of  epithelium,  slow  digestion  and  acidity  from  fermentation 
result;  because,  although  the  gastric  juice  is  sufficient,  it  cannot 
mix  as  readily  with  the  aliment. 

The  acids  formed  in  the  stomach  are,  besides  the  hydrochloric  acid 
of  the  gastric  juice,  lactic  acid,  acetic  acid,  carbonic  acid,  butyric 
acid,  and  oxalic  acid.  Some  articles  of  food  produce  these  differ- 
ent acids  in  considerable  quantities.  Thus,  sugar  generates  large 
amounts  of  lactic  acid.  The  mode  of  detecting  these  acids,  and 
of  establishing  whether  the  extreme  acidity  be  due  to  excess  of 
hydrochloric  acid  in  the  gastric  juice  or  to  other  acids,  as  tested 
after  a  trial  meal,  has  been  above  explained. 

The  acids  which  are  created  in  the  stomach  may  get  into  the 
blood,  and,  by  vitiating  this  fluid,  give  rise  to  various  disorders. 
When  much  acid  is  present  in  the  viscus,  it  occasions  a  sensation 
of  heat  which  extends  along  the  oesophagus.  This  "  heart-burn" 
is  apt  to  happen  in  paroxysms,  and  is  attended  with  a  feeling  of 
constriction  or  with  actual  pain  at  the  epigastrium.  As  a  symp- 
tom it  has  no  special  diagnostic  value,  for  it  is  met  with  both  in 
functional  and  in  organic  diseases  of  the  stomach.  It  simply  de- 
notes extreme  acidity ;  and  it  is  common  in  gouty  persons.  It 
probably  arises,  as  Chambers  surmises,  from  the  action  of  the  acid 
contents  of  the  organ  on  the  oversensitive  nerves  of  the  cardiac 
end  and  of  the  oesophagus.  When  the  acidity  is  due  to  excessive 
acidity  or  quantity  of  the  gastric  juice  it  is  the  result  of  a  sensory 
gastric  neurosis.  What  has  been  called  gastroxynsis  by  Rossbach 
is  a  gastric  neurosis  coming  on  at  intervals  mostly  after  some 
psychical  or  mental  disturbance,  and  marked  by  extremely  acid 
vomiting  and  headache,  like  that  of  migraine. 

Flatulency. — The  gas  in  the  intestinal  canal  may  be  merely 
air  which  is  swallowed ;  or  it  may  be  generated  from  imperfectly- 
digested  food  :  or  it  mav  be  a  secretion  from  tlie  blood-vessels  of 
the  part.  In  those  who  suffer  from  indigestion,  it  ?s  produced 
in  the  last  two  ways,  and  the  patient  complains  greatly  of  the 
annoyance  it  occasions.  It  causes  a  disgust  for  eating,  a  feeling 
of  distention,  and  sometimes  actual  pain.  By  interfering  with 
the  downward  movements  of  the  diaphragm,  it  induces  a  sensa- 


DISEASES   OF   THE   STOMACH.  405 

tion  of  constriction  in  tb.e  clicst,  sliortened  breathing,  palpitation 
of  the  heart,  and  the  sleep  is  broken  by  uneasy  dreams. 

An  expulsion  of  the  gaseous  contents  of  the  stomach  by  the 
mouth  gives  rise  to  eructation,  or  belching.  The  belching  which 
follows  the  decomposition  of  food  has  sometimes  the  taste  and 
the  odor  of  rotten  eggs,  owing  to  the  gas  evolved  consisting  of 
sulphuretted  hydrogen.  At  other  times  the  eructation  is  odorless, 
because  the  gases  formed  are  carbonic  acid,  or  hydrogen  or  nitro- 
gen, or  some  of  their  compounds.  When  the  gas  results  from 
fermentation  or  decomposition  of  food,  it  frequently  coexists  with 
acidity  occurring  only  after  meals.  When  it  is  a  secretion  from 
the  blood-vessels,  it  happens  in  an  empty  state  of  the  stomach, 
and  is  often  relieved  by  avoiding  too  long  intervals  between  the 
meals.  As  a  cause  of  flatulence  and  eructation  which  it  is  im- 
portant not  to  overlook  may  be  mentioned  thoracic  aneurism.* 
Extreme  flatulency  is  often  only  a  form  of  gastric  neurosis. 

Nausea  and  Vomiting. — These  are  often  combined.  But 
sometimes  there  is  persistent  nausea  without  vomiting ;  sometimes 
vomiting  occurs  without  any  or  with  but  slight  nausea.  Yet  they 
are  both  occasioned  in  much  the  same  way  :  what  gives  rise  to  one 
will  generally  give  rise  to  the  other. 

Vomiting  is  a  complex  act.  But  its  causes,  although  various, 
may  all  be  arranged  under  four  heads.  It  either  arises  from  an 
irritation  of  the  peripheral  extremities  of  the  nerves  which  sup- 
ply the  parts  more  directly  concerned  in  the  act  itself,  such  as 
the  stomach,  the  diaphragm,  and  the  oesophagus ;  or  the  irritation 
originates  in  the  centres  from  which  these  nerves  spring,  and  is 
referred  to  their  peripheries ;  or  there  is  a  mechanical  obstruction 
in  the  stomach  or  intestines  ;  or  the  vomiting  is  purely  sympa- 
thetic. Under  the  first  head  belongs  the  vomiting  observed  in 
acute  or  chronic  inflammation  of  the  stomach,  in  ulcer,  or  in  can- 
cer; also  that  following  a  debauch,  or  the  introduction  of  irri- 
tating substances  into  the  viscus.  Under  the  second  head  may  be 
.ranged  the  vomiting  which  occurs  in  diseases  of  the  brain  ;  per- 
haps, also,  that  which  arises  in  morbid  states  of  the  blood,  in 
Bright's  disease.  Under  the  third  head  we  may  class  the  vomit- 
ing in  narrowing  of  the  oesophagus  and  of  the  pyloric  or  cardiac 

*  Walter  F.  Atlee,  Amer.  Journ.  of  Med.  Sci.,  July,  1869. 


496  MEDICAL   DIAGNOSIS. 

extremity  of  the  stomach,  and  in  obstructions- of  the  intestine.  It 
is,  however,  a  question  whether  the  vomiting  in  all  these  cases  is 
not  owing  to  the  same  ultimate  cause  as  that  of  the  first  group  ; 
whether,  in  other  words,  it  is  not  a  reflex  phenomenon  called  forth 
by  the  irritation  at  the  seat  of  the  impediment. 

The  fourth  group  is  exemplified  by  the  vomiting  in  pregnancy, 
in  wounds  of  the  extremities,  in  inttammatiou  of  the  peritoneum, 
of  the  intestines,  and  of  the  liver,  in  renal  calculus,  and  in  irrita- 
tion of  the  fauces.  In  the  last  five  instances  the  vomiting  is  due 
to  direct  transmission  of  the  irritation,  and  must  be  looked  upon 
as  originating  through  means  of  that  sympathy  called  continuous. 
The  first  two  illustrate  tlie  remote  sympathy  between  different  parts 
of  the  body,  of  which  disease  often  furnishes  such  striking  proofs. 

Connected  thus  with  so  many  various  conditions,  the  act  of 
vomiting,  taken  by  itself,  is  of  little  diagnostic  value.  It  pre- 
supposes a  certain  amount  of  irritation  existing  in  the  stomach, 
or  reflected  to  it;  but  nothing  more.  It  is,  of  course,  a  frequent 
symptom  in  disorders  of  the  stomach,  especially  in  those  which  are 
organic;  yet  the  error  of  considering  it  as  having  reference  only 
to  derangements  of  that  viscns  ought  to  be  strenuously  guarded 
against.  As  it  is  allied  to  morbid  states  too  numerous  to  be  here 
examined  in  detail,  I  shall  content  myself  with  making  general 
statements  regarding  the  indications  to  be  drawn  from  it. 

When  vomiting  is  observed  in  a  person  previously  in  good 
health,  we  may  suspect  either  the  invasion  of  some  acute  malady, 
or  that  some  poisonous  substance  has  been  swallowed.  Again,  it 
may  come  on  suddenly  from  violent  mental  emotion.  When 
everything  that  is  taken  is  immediately  expelled,  the  difliculty 
lies  in  the  oesophagus,  or  at  the  cardiac  orifice  of  the  stomach, 
or  in  an  extreme  irritability  of  the  viscus ;  and  this  irritability, 
attended  as  it  often  is  with  unceasing  nausea,  experience  teaches 
to  be  more  frequently  due  to  sympathetic  excitement  of  the  organ 
than  to  structural  gastric  disease.  But  speedy  vomiting,  generally 
without  preceding  nausea,  it  must  be  remembered,  is  also  among 
the  symptoms  of  visceral  hysteria,  and  is  indeed,  by  some,  regarded 
as  the  most  frequent  symptom.*  I  have  known  it  associated  or 
alternating  with  extraordinary  flatulency. 

*  Denian,  L'Hysterie  gastrique,  Paris,  1883. 


DISEASES    OF    THE    STOMACH.  407 

Nervous  vomiting  occurs  where  there  is  no  lesion  in  tlie  stomacli  or 
irritation  of  food  as  the  cause.  It  is  mostly  reflex  in  consequence 
of  disease  of  the  uterus  or  the  liver,  or  from  direct  irritation  of 
the  nerve-centres  in  affections  of  the  brain  and  cord.  It  is  often 
found  in  hysterical  subjects.  It  is  not  associated  with  nausea,  and 
may  be  of  very  long  duration.  It  is  sometimes  a  primary  gastric 
neurosis. 

As  regards  the  vomiting  which  is  brought  about  l)y  gastric 
disorders,  it  is  of  much  consequence  to  note  the  period  at  which 
it  happens,  whether  before  meals  or  after  meals,  and  how  long 
afterward.  In  some  diseases,  such  as  ulcer  and  cancer,  it  rarely 
occurs  except  when  food  has  been  taken.  The  act  of  vomiting 
then  affords  relief  from  the  pain.  In  narrowing  of  the  pylorus,  it 
takes  place  some  hours  after  digestion  has  begun.  But,  as  vomit- 
ing; will  be  described  hereafter  in  its  relations  to  the  individual 
diseases  of  the  stomach,  we  shall  not  dwell  on  what  will  be  more 
fitly  discussed  elsewhere.  Yet  a  few  words  on  the  characteristics 
of  the  ejected  matter  can  hardly  be  omitted. 

The  nature  and  the  quantity  of  the  vomit  are,  of  course,  most 
various.     The  following  are  its  most  common  kinds : 

Food  or  liquid,  mixed  with  saliva  and  some  mucus,  is  expelled 
when  the  stomach  is  very  irritable,  or  if  an  obstruction  exist 
which  renders  the  entrance  into  the  organ  difficult  or  impossible. 
Half-digested  food,  in  a  state  of  acetous  fermentation  and  with  a 
strongly-acid  reaction,  is  cast  out  when  the  proper  secretion  of  the 
gastric  juice  has  been  interfered  with,  or  when  the  food  has  been 
detained  for  a  long  time  in  the  stomach.  In  the  ejected  matter 
the  particles  of  food  may  be  recognized ;  but  when  the  food  has 
been  kept  for  a  prolonged  period  in  the  stomach,  or  when  it  has 
passed  on  into  the  duodenum  and  is  returned,  it  is  changed  into 
an  apparently  homogeneous  mass.  Examined  under  the  micro- 
scope, the  structures  of  the  animal  or  vegetable  substances  par- 
taken of  can  even  then  be  detected.  Mixed  with  muscular  fibre, 
elastic  tissue,  starch-corpuscles,  and  vegetable  cells,  are  usually 
found  a  quantity  of  oil-drops  and  fat-crystals.  The  starch-cor- 
puscles are  turned  blue  by  a  solution  of  iodine  and  iodide  of 
potassium. 

Sarcinse  and  yeast  fungi  are  sometimes  discovered,  by  means  of 
the  microscope,  in  the  vomit.     These  organisms,  first  described  by 

32 


498  MEDICAL    DIAGNOSIS. 

John  Goodsir,  are  the  result  of  a  proeess  of  fermentation,  and  are 
generally  associated  with  copious  vomiting.  They  are  small  square 
or  slightly  oblong  bodies,  divided  into 
similar  smaller  portions  by  cross-lines, 
and  each  portion  thus  formed  is  again 
subdivided  ;  but  the  markings  of  the 
smaller  squares  are  not  so  distinct  as  those 
of  the  larger.  The  illustration  shows  a 
mass  of  sarcinte  found  in  the  vomit  of  a 

Sarcinse  ventriculi.  ,  •       ,        i  r-o        i    c  ■    •         i 

patient  who  suiiered  irom  gastric  nicer. 

Vomit  containing  sarcinse  is  always  indicative  of  structural 
change  in  the  stomach.  It  is  sometimes  found  in  chronic  gastritis 
of  long  standing ;  or  in  connection  with  ulcer,  and  yet  oftener 
with  cancer,  and  especially  in  those  cases  in  which  the  narrowing 
at  the  pyloric  extremity  has  led  to  distention  of  the  organ ;  indeed, 
some  condition  which  prevents  the  stomach  from  completely 
emptying  itself  pre-eminently  gives  rise  to  it. 

Sarcina  vomit  has  an  acid  smell  and  reaction,  and  often  a  pecu- 
liar brownish  appearance.  After  standing,  it  becomes  covered 
with  a  dirty,  frothy  matter,  like  yeast.  A  solution  of  iodine  and 
iodide  of  potassium  turns  the  sarcinse  mahogany  brown  or  a  violet 
hue  ;  but  it  is  by  the  microscope  that  their  presence  can  be  recog- 
nized with  greatest  certainty.  The  process  of  fermentation  at- 
tending the  develojiment  of  the  sarcinse  occasions  heart-burn  and 
extreme  flatulency,  and  the  copious  vomiting  is  a  source  of  relief. 

Uncus  is  occasionally  ejected  in  large  quantities,  both  mixed 
with  food  and  pure.  In  chronic  gastritis,  and  in  the  milder  forms 
of  acute  gastritis,  the  mucous  membrane  is  covered  -with  a  tena- 
cious secretion,  and  a  considerable  amount  of  a  glairy  or  stringy 
matter  is  expelled  by  the  act  of  vomiting.  As  a  general  rule, 
indeed,  it  may  l^c  stated  that,  when  much  mucus  is  evacuated, 
a  catarrhal  state  of  the  stomach  is  present. 

A  thin,  watery  fluid,  looking  much  like  saliva,  is  discharged  in 
some  cases  of  organic  disease  of  the  stomach,  and  more  frequently 
still  in  functional  derangement  of  the  organ  brought  on  by  eating 
coarse  food.  Now  and  then  it  is  met  with  in  pregnancy.  This 
variety  of  vomiting  is  popularly  known  as  "water-brash;"  tech- 
nically, as  2'>yrosis.  It  may  be  attended  with  a  burning  sensation 
extending  to  the  fauces,  and  with  pain  running  back  to  the  spine. 


DISEASES    OF    THE   STOMACH.  499 

Generally  it  is  a  tractable  disorder  if  proper  food  ])e  taken.  The 
fluid  is  commonly  alkaline ;  sometimes,  owing  to  its  intimate  ad- 
mixture with  the  gastric  contents,  it  is  acid.  Frerichs  foimd  that 
it  possessed  the  power  of  converting  starch  into  sugar.  On  this 
account,  it  has  been  presumed  to  be  saliva,  which,  after  having 
accumulated  in  the  stomach,  induces  vomiting.  It  is  mostly  re- 
garded as  being  formed  by  the  glands  at  the  lower  part  of  the 
oesophagus  as  well  as  of  the  stomach. 

Bile  may  find  its  way  into  the  stomach,  and  be  expelled  by  the 
mouth,  imparting  to  the  vomit  a  greenish  or  yellowish  color  and 
a  very  bitter  taste.  The  occurrence  of  bilious  vomiting  is  com- 
monly held  to  indicate  a  disease  of  the  liver,  or  that  the  patient  is 
extremely  ''  bilious."  It  is  not  a  j)roof  of  either.  It  is  observed 
when  there  is  much  retching,  and  when  the  act  of  vomiting  is 
protracted  and  frequently  repeated,  and  is  chiefly  met  with  in 
the  various  forms  of  acute  gastritis,  and  at  the  invasion  of  some 
acute  malady  which  gives  rise  to  sympathetic  disturbance  of  the 
stomach. 

Fsecal  vomiting  never  depends  upon  a  disease  of  the  stomach. 
It  may  possibly  be  owing  to  a  fistulous  opening  between  the  colon 
and  the  stomach ;  but  such  cases  are  extremely  rare.  Generally 
it  is  due  to  a  mechanical  obstruction  to  the  passage  of  faeces. 
Occasionally  it  happens  in  fevers  of  a  low  type,  or  in  peritonitis, 
and  is  then,  perhaps,  the  result  of  paralysis  of  a  portion  of  the 
intestinal  tube,  which  acts,  to  some  extent,  as  a  mechanical  ob- 
struction. The  matter  that  is  ejected  has  the  odor  of  fseces  ;  but 
it  is  commonly  of  less  firm  consistence,  and  of  lighter  color,  be- 
cause it  is  the  contents  rather  of  the  small  than  of"  the  large 
intestine.  Sometimes  it  is  perfectly  fluid.  In  fsecal  vomit  a  con- 
siderable number  of  large  comma-like  bacilli  have  been  noticed.* 

It  is  commonly  supposed  that  fsecal  vomiting  is  caused  by  an 
inversion  of  the  natural  peristaltic  action  of  the  bowel.  This  doc- 
trine was  called  in  question  by  William  Brinton.  He  attributes 
the  reflux  of  fsecal  matter  to  the  peristalsis  itself,  which,  acting  on 
an  obstructed  and  distended  bowel,  occasions  on  the  periphery,  as 
far  as  possible,  the  forward  propulsion  of'  the  contents  of  the 
intestinal   tube,  but   which  also  gives  rise  to  a  current  in  the 

*  Jaksch,  Klinische  Diagnostik,  1887. 


500  MEDICAL   DIAGNOSIS. 

opposite  tlircftion  in  tlit-  lliiid  t>ubstanccs  occupying  the  centre 
of  the  tube.^= 

Pus  hi  small  amount  is  sometimes  found  mixed  with  the  vomit 
in  cases  of  large  ulcers  in  the  stomach,  simple  or  cancerous. 
When  in  quantities,  it  is  owing  to  an  abscess  in  the  neiglibor- 
hood  of  the  viscus  having  poured  its  contents  into  it.  Still,  pus 
is  rarely  met  with  in  the  matters  expelled.  And  the  same  can  be 
said  of  other  substances  Avhich  may  find  their  way  into  the 
stomach,  like  eehinococcus  sacs  and  worms,  and  also  of  masses 
of  false  membrane. 

Blood,  on  the  other  hand,  is  not  infrequently  vomited.  Having 
described  the  appearance  of  the  blood  when  it  comes  from  the 
stomach,  in  treating  of  the  diagnosis  of  hemorrhage  from  the 
lungs,  I  shall,  before  examining  into  the  cireumstanccs  Mhich 
cause  a  h^ematemesis,  merely  here  recall  the  fact  that  it  is  pre- 
ceded by  nausea  and  followed  by  black  stools,  and  that  the  fluid 
ejected  is  generally  black,  and  presents  an  acid  reaction. 

The  quantity  of  blood  lost  varies  greatly ;  but  the  amount 
vomited  is  by  no  means  a  proof  of  the  amount  eifused.  The 
larger  portion  may  pass  off  by  the  bowels,  giving  rise  to  peculiar 
tarry  stools.  jN^ay,  the  whole  may  be  voided  with  the  stools. 
Chocolate-colored  material  discharged  by  stool,  and  due  to  alka- 
line fluids  acting  on  the  blood  after  the  effect  of  acids,  is  held  to 
be  a  distinguishing  trait  between  the  blood  passing  by  the  intes- 
tines after  a  gastric  hemorrhage  and  bleeding  from  the  bowel. f 

Hemorrhage  from  the  stomach  is  variously  caused.  It  may 
spring  from  injury  to  the  organ,  or  from  disease  of  its  coat ;  it 
may  be  vicarious  ;  it  may  be  the  consequence  of  disorder  else- 
where than  in  the  stomach,  as  of  a  mechanical  obstruction  in  the 
portal  system ;  it  may  depend  upon  an  altered  state  of  the  blood. 

In  the  hemorrhage  that  follows  blows  or  kicks  on  the  stomach, 
an  active  hyperajmia  of  the  mucous  surface  is  occasioned,  which 
•  leads  to  the  extravasation  of  blood.  An  active  arterial  hypersemia 
also  precedes  the  hemorrhage  that  sometimes  follows  the  swal- 
lowing of  irritant  poisons ;  and  it  is  probably  the  cause  of  the 
hsematemesis  in  several  of  the  organic  affections  of  the  stomach. 


*  Intestinal  Obstruction,  London,  18G7. 
f  Bartholow,  Practice  of  Medicine. 


DISEASES    OF   THE   STOMACH.  501 

Of  these,  only  cancer  and  ulcer  are  apt  to  present  hemorrhage  as 
a  prominent  symptom ;  and  of  these,  again,  it  is  much  more  fre- 
quent in  the  latter  than  in  the  former.  The  blood  effused  may 
be  so  slight  in  amount  as  to  escape  detection  ;  and  this  is  especially 
likely  to  happen  when  it  is  intimately  admixed  with  food  or  with 
bile.  Yet,  by  means  of  the  microscope,  the  existence  of  blood- 
corpuscles  in  the  ejected  matter  can  be  always  demonstrated.  The 
fulness  of  the  vessels  may  be  associated  with  degeneration  of  their 
coats,  as,  for  instance,  in  amyloid  degeneration  of  the  stomach. 

When  blood  has  been  detained  for  some  time  in  the  stomach, 
and  has  become  intimately  mingled  with  the  acid  contents  of  the 
organ,  it  loses  entirely  its  natural  appearance.  What  is  termed 
"  coffee-ground  vomit"  is  blood  thoroughly  intermixed  with  other 
substances.  It  is  the  result  of  a  comparatively  small  or  gradual 
hemorrhage  ;  and,  as  this  is  the  kind  which  is  apt  to  happen  in 
gastric  cancer,  it  is  common  in  this  affection.  It  has  been  held  to 
be  pathognomonic  of  it ;  but  it  is  not.  It  occurs  in  other  morbid 
states  of  the  organ. 

Vicarious  hemorrhage  from  the  stomach  is  not  infrequent,  and 
especially  frequent  is  that  which  takes  the  place  of  the  menses. 
It  is  not  dangerous.  The  blood  escapes  at  the  time  of  the  normal 
discharge,  and  while  the  bleeding  lasts  the  stomach  is  slightly 
tender,  and  the  digestion  impaired.  But  during  the  intervals  there 
are  no  signs  of  disturbance  of  the  functions  of  the  organ,  and  no 
pain ;  both  of  which  are  points  of  importance  in  distinguishing 
between  loss  of  blood  caused  by  suppressed  menstruation  and  loss 
of  blood  caused  by  disease  of  the  stomach. 

Gastric  hemorrhage,  dependent  upon  a  state  of  passive  congestion 
brought  on  by  an  obstruction  to  the  flow  of  venous  blood,  is  occa- 
sionally seen  in  organic  affections  of  the  heart.  But  it  is  much 
more  common  as  the  result  of  embarrassment  of  the  portal  cir- 
culation, from  tumors,  or  from  affections  of  the  liver  and  spleen. 
It  frequently  attends,  therefore,  cirrhosis  and  enlargement  of  the 
spleen,  and  is  often  joined  to  intestinal  hemorrhage. 

In  srastric  hemorrhage  resulting  from  chano-es  in  the  blood  the 
vessels  themselves  are  toneless,  and  rupture  easily  or  offer  no  resist- 
ance to  their  altered  contents  escaping.  This  kind  of  hemorrhage 
is  met  with  in  scurvy,  in  typhus  fever,  and  in  yellow  fever. 

We  see  thus  that  blood  is  vomited  from  various  causes,  and 


502  MEDICAL   DIAGNOSIS. 

that  nieivlv  from  the  oceunvnce  of  luematemesis  wc  can  dctor- 
niine  notliinii"  definite  as  to  its  origin.  Yet  the  symptom — for  a 
symptom  it  always  is — is  of  serious  import,  and  when  taken  in 
connection  with  others  is  of  great  service  in  diagnosis.  We 
ouglit,  in  chronic  cases,  first  to  suspect  the  hemorrhage  to  be  due 
to  some  organic  disease  of  the  stomach ;  when  there  is  no  other 
proof  of  a  structural  aifection  of  this  organ,  we  turn  to  the  liver, 
spleen,  or  heart  for  its  explanation,  or  examine  carefully  every 
part  of  the  abdominal  cavity,  to  see  whether  or  not  a  tumor  is 
the  source  of  the  trouble.  If  occasioned  by  none  of  these  con- 
ditions, its  cause  lies  probably  in  altered  blood,  or  in  su])prcssed 
discharges.  Of  course  the  history  of  the  case  is  indispensable  to 
any  induction.  Thus,  in  low  fevers  there  is  no  doubt  as  to  what 
has  brought  about  the  hemorrhage. 

There  is,  however,  one  difficulty  present  in  all  instances ;  and 
that  is,  to  tell  whether  the  ejected  blood  has  found  its  way  into 
the  stomach  and  has  been  subsequently  expelled,  or  whether  the 
hemorrhage  is  really  gastric.  The  only  method  to  avoid  being 
deceived  is  to  scrutinize  closely  the  history  and  the  attending 
phenomena.  Blood  may  be  introduced  into  the  stomach  by  the 
bursting  of  an  aneurism,  or  from  an  ulcerating  pancreas;  or 
it  may  have  been  swallowed  during  an  attack  of  epistaxis  or  of 
haemoptysis,  or  wilfully,  to  excite  sympathy  or  to  escape  pun- 
ishment. A  strange  result  of  gastric  hemorrhage,  first  noticed 
by  Graefe,  is  double-sided  incurable  amaurosis. 

So  much  for  vomiting  of  blood,  and  for  the  different  characters 
presented  by  the  vomit.  In  describing  them  we  have  been  led 
away  from  the  indications  they  furnish  in  diseases  of  the  stomach. 
But  it  was  more  convenient  here  to  consider  vomiting  connectedly 
and  somewhat  in  detail,  than  to  be  obliged  to' treat  of  it  in  various 
chapters.  To  return  now  to  the  more  special  symptoms  of  a 
deranged  stomach. 

Fain. — Pain  occurs  in  gastric  disorders  in  every  conceivable 
form.  It  is  sometimes  slight,  at  other  times  violent.  It  is  often 
more  a  feeling  of  soreness  than  actual  pain.  It  may  or  may  not 
be  increased  by  pressure,  and  may  either  be  augmented  or  relieved 
by  the  taking  of  food.  If  persistent  or  severe,  and  accompanied 
by  tenderness  at  the  epigastrium,  it  is  almost  always  linked  to  a 
morbid  state  of  the  tissues  of  the  viscus.      Mere  uneasy  sensa- 


DISEASES   OP  TPIE   STOMACH.  503 

tions,  on  the  other  hand,  also  happen  in  functional  derangement 
of  the  organ  while  the  food  is  being  digested,  and  may  even  be 
attended  with  slight  tenderness  at  the  epigastrium. 

Now,  as  both  pain  and  soreness  to  the  touch  may  be  present  as 
well  in  functional  disturbance  as  in  organic  change,  how  can  we 
tell  with  which  they  are  associated  ?  Budcl  *  lays  down  a  law  on 
this  point  which,  on  the  whole,  is  borne  out  by  the  experience  of 
the  profession.  The  pain  and  soreness,  he  affirms,  dependent  on 
organic  disease  may  be  distinguished  from  the  pain  and  soreness 
which  result  from  functional  disorder  by  noticing  the  time  at 
which  they  take  place.  If  they  are  more  severe  soon  after  meals, 
or  when  the  stomach  is  full,  and  more  severe  after  a  heavy  meal 
of  animal  food  than  after  a  light  one  of  farinaceous  substances 
and  milk,  they  point  to  a  structural  affection.  If  they  occur  only 
when  the  stomach  is  empty,  and  are  relieved  by  food,  they  are 
indicative  of  a  functional  derangement.  This  general  rule  is  as 
true  as  most  general  rules  ;  but  no  truer. 

Occasionally  the  stomach  is  the  seat  of  violent  paroxysms  of 
pain.  These  are  at  times  linked  to  a  chronic  organic  affection ;  at 
others  they  are  apparently  connected  with  a  perfectly  sound  state 
of  the  viscus,  and  coexist  with  a  tendency  to  neuralgic  pains  all 
over  the  body ;  at  others,  again,  they  are  brought  about  by  some 
article  of  food  which  the  stomach  does  not  tolerate  or  is  unable 
to  digest.  The  disorder  is  variously  described  under  the  name  of 
gastrodynia  or  gastralgla.  The  pain  is  supposed  to  be  associated 
with  or  due  to  a  cramp  of  the  stomach ;  but  whether  it  is  so  or 
not  is  far  from  certain.  When  the  predisposition  to  it  exists, 
exposure  to  cold  and  damp,  a  draught  of  cold  water  drunk  when 
heated,  sudden  and  violent  emotions,  or  a  collection  of  wind  in 
the  alimentary  canal,  will  bring  it  on.  And  this  predisposition  is 
met  with  in  gouty  and  rheumatic  persons,  and  in  those  who  are 
debilitated, — in  women  who  are  anaemic,  and  in  men  who  have 
been  exposed  to  exhausting  influences.  Then  we  also  find  the 
gastralgia  interchanged  with  other  neuralgic  or  spasmodic  affec- 
tions, giving  way  to  asthma  or  to  angina  pectoris,  or,  on  the  other 
hand,  occurring  in  their  place. 

The  pain  varies  much  in  intensity  :  it  is   usually  severe  and 

*  Diseases  of  the  Stomach. 


504  MEDICAL    DIAGNOSIS. 

agonizing;  but  it  is  not  permanent;  intervals  of  rest  and  comfort 
succeed  to  the  paroxysms  of  distress.  During  a  violent  attack,  the 
skin  is  cold,  the  pulse  slow,  there  are  frequently  nausea,  vomiting, 
sometimes  fainting,  and  often  sensations  of  utter  prostration  and 
impending  disst)lution.  The  seat  of  the  pain  is  in  tlic  epigastrium, 
immediately  beneath  the  ensiforni  cartilage.  Tiie  patient  feels  as 
if  the  coats  of  the  stomach  were  being  violently  drawn  together, 
or  rent  asunder,  or  rapidly  pierced  by  a  sharp  instrument.  Thence 
the  pain  extends  toward  the  umbilicus  and  the  hy[)och()ndria.  It 
is  sometimes  relieved  by  the  recumbent  position  and  l)y  external 
pressure.  But  relief  depends  much  on  the  condition  with  Avhich 
the  pain  is  associated.  If  it  be  connected  with  a  chronic  gastritis 
or  an  ulceration,  external  pressure  aggravates  ratlier  than  allevi- 
ates it.  This  is  certainly  true  as  a  rule;  yet  we  cannot  positively 
announce  that  pain  with  tenderness  at  the  epigastrium  is  proof  of 
an  organic  lesion.  There  is  sometimes  sensitiveness  to  the  touch 
in  purely  nervous  gastralgia ;  or  slight  pressure  may  augment  the 
pain,  but  firmly  compressing  the  pit  of  the  stomach  will  diminish  it. 
In  a  practical  point  of  view,  it  is  very  important  to  discrimi- 
nate between  the  cases  of  gastralgia  which  may  be  vic\ved  as  pure 
neuroses  and  those  in  which  the  paroxysms  of  pain  are  combined 
with  a  chronic  lesion.  AVe  infer  that  we  have  to  deal  with  instances 
of  the  former,  when  the  attacks  occur  in  thotije  whose  impoverished 
blood  or  enfeebled  health  predisposes  to  neuralgia,  and  especially 
if  they  happen  in  women  laboring  under  disorders  of  the  uterus 
or  ovaries,  or  in  persons  who  suffer  from  neuralgic  pains  in  other 
parts  of  the  body.  But  the  broadest  line  of  distinction  is  drawn 
from  the  state  of  the  digestive  apparatus  during  the  intervals. 
The  disordered  digestion,  the  pain  after  eating,  the  tenderness  at 
the  epigastrium,  the  nausea  and  vomiting,  and  the  other  symptoms 
common  in  morbid  alterations  of  the  coats  of  the  stomach,  are  not 
seen  in  pure  neuralgic  gastrodynia.  I  have  already  stated  that 
too  much  stress  ought  not  to  be  laid  on  the  influence  of  pressure 
on  the  paroxysmal  pain  during  the  paroxysm.  A  sign  more  trust- 
worthy is  the  alleviation  folluMing  the  taking  of  food,  for  which, 
in  truth,  there  may  be  a  craving;  and  occasionally  cases  of  gas- 
tralgia are  met  with  in  which  the  pain  occurs  only  early  in  the 
mornings,  and  is  very  distressing,  but  is  almost  immediately  eased 
by  a  hearty  breakfast. 


DISEASES    OF   THE   STOMACH.  505 

The  form  of  gastrodynia  which  is  produced  l)y  some  article 
of  food  that  disagrees  with  the  individual  is  readily  distinguished 
from  the  other  varieties  by  observing  it  to  be  transient,  and  by 
noting  its  cause.  The  indigestible  substance  undergoes  fermenta- 
tion in  the  stomach,  and  acidity,  flatulent  distention,  and  nausea 
attend  the  pain,  which  ceases  when  the  offending  matter  is  ejected 
and  the  gas  expelled. 

The  remarks  just  made  apply  also,  in  the  main,  to  other 
manifestations  of  perverted  innervation  of  the  stomach,  such  as 
hypersesthesia,  erethism,  with  or  without  persistent  vomitings, — 
forms  happening  usually  in  weak  or  hysterical  persons,  but  which 
in  the  present  state  of  our  knowledge  are  still  conveniently  classed 
with  gastralgia  as  forms  of  gastric  neuroses. 

The  nervous  filaments,  the  irritation  of  which  occasions  pain 
in  the  stomach  Mdiether  paroxysmal  or  not,  belong  to  the  vagus ; 
sometimes,  perhaps,  the  distress  originates  in  the  branches  of  the 
sympathetic  that  supply  the  organ.  But  we  must  be  careful  not 
to  ascribe  the  seat  of  every  pain  which  is  felt  between  the  umbili- 
cus and  sternum,  or  referred  there,  to  the  stomach.  Diseases  of 
the  pleura,  of  the  heart  and  its  covering,  affections  of  the  inter- 
costal nerves,  abscess  of  the  liver,  intestinal  disorders,  rheumatism 
of  the  abdominal  muscles,  may  give  rise  to  pain  in  the  epigastric 
region.  And,  again,  spasmodic  pain  like  that  of  gastralgia  may 
be  caused  by  colic,  by  disorganization  of  the  tissue  of  the  kidney 
and  of  the  pancreas,  and  by  the  passage  of  gall-stones  or  of  renal 
calculi.  The  great  safeguard  against  error  is  to  bear  in  mind 
that  painful  complaints  of  the  stomach  may  be  mistaken  for  those 
enumerated,  and  to  ascertain  carefully,  in  cases  of  epigastric  dis- 
tress, that  there  is  no  cause  beyond  the  stomach  to  account  for  it. 
The  nearer,  in  many  instances,  the  pain  is  to  the  median  line,  or, 
should  it  occupy  this,  the  more  fixed  and  confined  to  a  small  spot, 
the  greater  is  the  probability  of  its  being  dependent  upon  gasti'ic 
disease ;  and  pain  of  the  character  alluded  to  is  generally  indica- 
tive of  serious  malady. 

Pain  is  the  last  of  the  symptoms  directly  referable  to  the  de- 
rangement of  the  viscus  itself  to  which  we  shall  advert.  But 
when  the  great  organ  of  assimilation  is  disordered,  other  organs 
suffer,  either  through  sympathy,  or  because  the  irritation  is  trans- 
mitted to  them,  or  because  a  similar  state  of  their  muc-ous  surface 


506  MEDICAL    DIAG^'OSIS. 

is  indnccd.  The  bowels  are  usually  in  a  sluggish  condition  ;  it  is 
commonly  only  when  the  gastric  acidity  is  extreme  that  they  arc 
rdaxcd.  The  viscera  within  the  chest  are  frequently  disturbed. 
The  patient  is  annoyed  by  palpitation  and  shortness  of  breath 
after  meals ;  and  as  he  feels  the  agitation  of  his  heart,  and  finds 
that  always,  after  he  has  eaten,  his  face  is  flushed,  the  palms  of 
his  hands  are  hot,  and  his  temporal  arteries  throbbing,  he  is  apt 
to  overlook  the  derangement  of  the  stomach,  and  to  fancy  himself 
laboring  under  an  incurable  cardiac  affection.  A  dry  cough,  also, 
is  a  not  unusual  concomitant ;  but  a  cough  may  be  the  result  of 
coexisting  catarrh  of  the  bronchial  mucous  membrane,  or  of  dis- 
ease of  the  lung-structure;  and  sometimes  the  affection  of  the  lungs 
precedes  that  of  the  stomach.  Again,  we  may  have  an  organic 
disease  of  the  heart  determining  the  gastric  symptoms. 

So,  too,  with  the  kidneys.  They  riiay  be  irritated  by  the  crude 
material  which  has  made  its  way  into  the  blood,  and  which  they 
are  called  upon  to  excrete.  The  urine  often  contains  various  ab- 
noi'mal  constituents,  especially  ui'atcs ;  yet  not  seldom  a  morbid 
state  of  the  urine  is  found  previous  to  the  derangement  of  the 
stomach,  and  the  indigestion  is  the  secondary  rather  than  the 
primary  ailment.  Indeed,  we  must  never  be  too  hasty  in  con- 
cluding, when  a  disordered  stomach  is  associated  with  diseases  of 
other  viscera,  that  it  is  their  cause ;  it  may  exist  as  their  conse- 
quence. Diseases  of  the  liver  and  intestines  are  especially  prone 
to  induce  a  gastric  affection. 

One  of  the  worst  results  of  a  disordered  digestion  is  the  state 
of  mind  it  produces.  It  occasions  listlessness  and  a  disposition 
to  look  at  all  events  in  a  gloomy  light,  and  sometimes  brings  on 
inveterate  hypochondriasis.  Aretfeus  ascribed  to  the  stomach  as 
its  primary  power  that  it  acted  as  the  president  of  i)leasure  and 
of  disgust,  "being,  from  the  sympathy  of  the  soul,  an  important 
neighbor  to  the  heart  for  imparting  good  or  bad  spirits."  JS^ow, 
although  no  one  at  present  would  agree  with  the  physiology  of 
the  learned  Cappadocian,  who  will  deny  that  there  is  in  the 
remark  a  germ  of  truth  ?  But  here,  again,  we  must  be  careful 
not  to  confound  cause  with  effect ;  for  want  of  activity  or  a  dis- 
tressed state  of  mind  may  seriously  impair  the  appetite  and  sub- 
vert the  normal  action  of  the  viscus.  When  the  nervous  symp- 
toms are  marked,  the  disorder  is  often  called  "  nervous  dyspepsia." 


DISEASES   OF   THE   STOMACH.  507 

In  this,  while  the  gastric  symptoms  are  slight,  we  may  also  have 
the  gastric  neurasthenia  leading  to  extreme  acidity  of  the  gastric 
juice,  to  eructations,  to  flatulency. 

In  the  rough  sketch  just  finished  of  the  symptoms  encountered 
in  gastric  disorders,  no  attempt  has  been  made  to  separate  the 
signs  which  belong  more  particularly  to  alteration  of  its  coats 
from  those  which  occur  in  derangement  of  its  functions ;  in  other 
words,  I  have  not  tried  to  dissociate  the  symptoms  of  "  dyspepsia" 
from  those  of  actual  lesions.  And  this  for  two  reasons :  in  the 
first  place,  the  most  palpable  indications  of  organic  disease  of  the 
stomach  are  those  of  disordered  function ;  and  secondly,  there  are 
no  symptoms  which  belong  exclusively  to  mere  dyspepsia.  This 
complaint  consists  simply  of  the  phenomena  of  indigestion,  but 
in  infinitely-varied  combination  :  in  some  cases  we  find  pain  ;  in 
others,  nausea  and  disgust  for  food ;  in  others,  again,  uneasiness 
after  meals,  and  acid  eructations,  or  flatulency ;  in  some  the  gas- 
tric symptoms  are  connected  with  debility,  with  great  depression 
of  spirits,  and  Avith  wasting ;  in  others  a  fair  amount  of  health  is 
preserved,  the  appetite  is  uncertain  or  perverted,  and  the  signs  of 
indio^estion  are  manifest  onlv  after  certain  articles  of  food  have 
been  partaken  of;  in  some  cases  the  nervous  symptoms  are  more 
prominent  than  the  gastric ;  in  others  the  dyspeptic  symptoms 
may  be  the  most  marked,  although  the  real  cause  is  an  exhausted 
state  of  the  nervous  system. 

Thus  it  is  impossible  to  present  anything  like  a  complete 
picture  of  merely  functional,  or,  as  it  is  called  by  some,  atonic 
dyspepsia.  jS^or  is  this  necessary  ;  for  its  main  features  are  easily 
enough  recognized.  In  truth,  the  liability  to  error  lies  in  an 
opposite  direction.  The  faulty  performance  of  the  act  of  diges- 
tion is  too  often  regarded  as  the  whole  ailment.  Too  often,  if 
the  physician  have  made  out  the  diagnosis  of  "dyspepsia,"  he 
seeks  no  further,  and  treats  the  patient  for  this,  and  this  alone, 
by  means  of  some  of  the  interminable  mixtures  which  enjoy  the 
reputation  of  being  "  good  for  dyspepsia."  It  is  true  that  in  an 
organ  like  the  stomach  it  is  particularly  difficult  to  tell  where 
disturbed  function  ceases  and  anatomical  change  begins.  Still, 
that  this  can  be  done  to  a  greater  extent  than  it  is  usually  done, 
cannot  be  gainsaid.  Moreover,  there  are  many  affections  which 
probably  have  connected  with  them  definite  anatomical  lesions 


508  MEDICAL   DIAGNOSIS. 

and  constant  modifications  of  the  gastric  juice  and  of  the  secre- 
tions of  the  mucous  follicles  of  the  stomach,  which  we  are  as  yet 
obliged  to  embrace  under  the  name  of  dyspepsia,  because  we  are 
unacquainted  with  their  clinical  expression.  But  we  may  fairly 
expect  that,  through  those  admirable  physiological  and  pathologi- 
cal researcJies  which  have  of  late  begun  to  illuminate  the  subject, 
the  limits  of  purely  functional  dyspepsia  will  be  much  reduced; 
so  that  what  the  physician  of  the  present  day  is  compelled  to 
class  under  the  general  term  dysjwpsia  will  be  recognized  by  the 
physician  of  the  twentieth  century  as  several  distinct  affections, 
cac-h  with  its  characteristic  structural  change, — much  in  the  same 
way  that  the  physician  of  the  eighteenth  century  was  oljliged  to 
regard  and  to  treat  dyspnoea  as  an  individual  disease,  Avhile  now 
we  have  learned  to  separate  it  into  different  varieties,  in  conformity 
with  its  prominent  anatomical  causes,  and  to  treat  it  in  accordance 
with  its  source. 

Diseases  of  the  Stomach  in  which  Pain  and  Soreness  at  the 
Epigastrium,  and  Voniiting,  occur, 

After  what  has  been  premised,  it  is  obvious  that  the  structural 
diseases  of  the  stomach  present  but  few  symptoms  which  can  be 
regarded  as  at  all  characteristic.  Indeed,  the  only  ones  which 
can  lay  any  claim  to  be  so  considered — and  we  have  already  seen 
that  this  claim  is  not  always  valid — are  pain  and  soreness  at  the 
epigastrium,  and  vomiting.  We  may,  then,  take  these  symptoms 
as  a  starting-point  in  diagnosis,  and  describe  the  individual  organic 
affections  in  which  they  chiefly  occur,  speaking  first  of  the  acute. 

Acute  Gastritis. — This  malady  is  pronounced  to  be  exceed- 
ingly rare,  save  as  the  result  of  irritant  poisons.  Undoubtedly, 
inflammation  of  an  intense  kind,  involving  more  than  the  mucous 
membrane,  originating  spontaneously,  and  not  from  the  introduc- 
tion of  any  highly  acrid  or  corrosive  substance,  is  very  seldom  met 
with.  But  it  is  no  less  certain  that  inflammation  of  a  less  active 
character,  limited  to  the  most  important  part  of  the  stomach,  to 
the  mucous  membrane,  and  especially  to  its  surface,  is  far  from 
being  a  rare  disease,  and,  whether  as  a  concomitant  of  fevers  or 
as  an  idiopathic  malady,  is  a  disorder  to  which  the  physician's 
attention  is  constantly  drawn. 

Thus,  then,  acute  inflammation  of  all  the  coats  of  the  stomach, 


DISEASES   OF   TIIE   STOMACH.  509 

or  even  of  the  entire  mucous  membrane,  is  uncommon ;  acute  in- 
flammation of  its  surface  is  common.  Yet  it  is  the  doctrine  of 
the  day  not  to  regard  any  case  as  acute  gastritis  unless  serious 
changes  have  been  wrought  by  the  inflammation  in  the  tissues  of 
the  organ,  so  serious  as  almost  to  preclude  recovery.  To  discuss, 
in  a  work  of  this  kind,  the  correctness  or  incorrectness  of  this 
view  would  hardly  be  justifiable.  But,  before  proceeding,  I 
venture  to  submit  whether  the  limits  within  which  acute  inflam- 
mation is  supposed  to  be  confined  are  not  more  rigidly  marked 
out  for  the  stomach  than  for  any  other  viscus ;  whether  it  is  not 
very  arbitrary  and  artificial  to  make  severity  and  consequence  the 
test  of  acute  inflammation ;  and  whether  a  state  of  things  fully 
entitled  to  be  called  acute  idiopathic  gastritis  is  not  more  frequent 
than  is  generally  admitted.  I  am  sure  that  I  have  seen  cases  which 
differed  in  nothing  from  the  typical  and  graphically-described 
cases  of  Andral,*  save  in  the  fatal  termination  and  in  lacking 
the  symptoms  which  immediately  precede  that  termination. 

I  shall  detail  one  which  was  striking.  A  robust  woman,  the 
mother  of  several  children,  whom  she  was  obliged  to  support  by 
hard  labor,  was  suddenly  seized  with  a  pain  in  the  epigastric 
region,  and  vomiting.  There  was  no  apparent  cause  for  the  at- 
tack :  she  had  certainly  not  swallowed  any  irritating  substance. 
Although  at  one  time  a  sufferer  from  indigestion,  her  digestive 
organs  had  not  been  markedly  disordered  for  weeks  prior  to  the 
appearance  of  the  pain  and  the  irritability  of  the  stomach.  The 
former  seemed  to  come  on  before  the  latter.  It  was  of  a  dull 
character,  increased  by  swallowing  either  solids  or  liquids,  and 
associated  with  the  greatest  tenderness.  Nausea  was  constant,  and 
vomiting  very  frequent.  Large  quantities  of  a  greenish  fluid 
were  ejected,  as  well  as  nearly  everything  she  swallowed.  The 
tongue  was  deeply  coated  ;  its  edges  and  tip  were  red.  The  bowels 
were  constipated,  but  not  painful  on  pressure.  There  was  fever, 
— not,  however,  of  an  active  type ;  it  rose  toward  evening ;  the 
pulse  was  quick  and  small ;  the  breathing  was  hurried,  and  the 
patient  exceedingly  restless  and  prostrated.  She  complained  most 
of  the  distress  in  her  head,  and  of  violent  thirst.  The  treatment 
pursued  consisted  mainly  in  opening  the  bowels  by  enemata,  and 

*  Clinique  Medicale,  tome  ii. 


510  MEDICAL   DIAGNOSIS. 

in  administering;  ice  and  repeated  doses  of  calomel,  some  of  which 
she  retained.  After  the  symptoms  had  lasted  for  about  ten  days, 
they  gradually  disappeared,  and  she  slowly  recovered.  The  pain 
on  swalh)wing-  and  tiie  soreness  at  the  epigastrium  were  the  last  to 
leave.  Indeed,  when  she  passed  from  under  my  care  they  had 
not  ceased  entirely. 

Now,  here  is  a  case  which  presented  all  the  symptoms  of  a 
severe  inflammation  of  the  stomach,  similar  to  that  produced  when 
an  irritant  poison  has  been  received  into  the  organ.  In  all  such 
instances  there  are  the  same  nausea  and  vomiting,  and  pain;  the 
same  restlessness  and  headache  ;  the  same  form  of  fever  and  small 
or  feeble  pulse ;  the  same  unquenchable  thirst.  Sometimes  the 
pain  is  of  a  burning  kind  ;  and  in  those  cases  which  prove  fatal 
— ^and  many  do  prove  fatal,  as  much  perhaps  from  the  destructive 
effect  of  the  irritant  on  the  tissues  as  in  consequence  of  the  inflam- 
mation— there  is  hiccough,  the  skin  becomes  cold,  the  features  col- 
lapse, and  the  sufferer  dies  prostrated,  yet  frequently  preserving 
his  mental  faculties  to  the  last. 

From  these  severe  cases  of  acute  gastritis,  however  caused,  there 
exists  every  grade  of  inflammation,  down  to  an  active  congestion 
of  the  mucous  membrane,  and  to  a  mere  reddening  of  its  surface. 
Of  course,  there  will  not  be  in  the  milder  forms  the  same  intensity 
in  the  symptoms.  But  the  outline  is  the  same,  although  the  filling 
in  be  in  far  less  vivid  hues.  There  is  in  all  the  same  tendency  to 
nausea  and  to  vomiting,  with  more  or  less  epigastric  pain  and 
uneasy  sensations,  and  more  or  less  tenderness  at  the  pit  of  the 
stomach,  and  headache. 

A  mild  gastritis  is  very  commonly  brought  on  by  a  debauch  or 
by  the  introduction  of  irritating  articles  of  diet  into  the  stomach. 

These  cases  are  classed  as  acute  gastric  catarrh,  and  are  popu- 
larly known  as  severe  attacks  of  indigestion  :  that  they  are  owing 
to  an  inflammatory  state  of  the  mucous  membrane  was  proved  by 
the  ocular  demonstration  Beaumont  had  of  the  process  in  the 
person  of  Alexis  St.  Martin.  The  symptoms  that  inflammatory 
change,  when  it  was  marked,  produced,  were  some  tenderness  at 
the  epigastrium  ;  nausea ;  vomiting ;  constipation,  or  sometimes 
diarrhoea ;  a  coated  tongue,  and  headache, — in  fact,  just  the  symp- 
toms of  which  patients  complain  when  they  are  suffering  from  an 
acute  attack  of  indigestion. 


DISEASES   OP   THE   STOMACH.  511 

Another  common  and  kindred  kind  of  mild  inflammation  of 
the  stomach  or  acute  gastric  catarrh  is  that  usually  called  a 
"  bilious  attack."  The  French  designate  it  expressively  as  em- 
harras  gastrique.  It  is  a  catarrhal  affection,  and  often  associated 
with  catarrh  of  other  mucous  membranes.  It  may  come  on  from 
indigestible  food,  or  after  cold  and  exposure;  it  sometimes  occurs 
in  epidemics.  The  symptoms  are  those  already  detailed.  There 
is  nausea,  and  frequently  bile  is  vomited.  We  do  not  usually 
observe  much  pain  in  the  epigastrium  ;  but  rather  a  feeling  of 
uneasiness,  and  a  slight  soreness  to  the  touch.  The  urine  is  dark, 
and  deposits  urates ;  the  tongue  is  much  coated ;  there  is  thirst, 
with  generally  a  moderate  or  slight  fever,  which  exacerbates  at 
night,  and  is  of  remittent  type,  and  there  may  be  a  yellowish 
tinge  of  the  conjunctivae. 

Secondary  acute  inflammation  of  the  mucous  membrane  of  the 
stomach  is  found  in  association  with  various  disorders.  It  is  met 
with  in  remittent  fever,  in  typhus,  in  the  exanthemata,  in  rheu- 
matism, and  oftener  in  gout,  and  partakes  somewhat  of  the  specific 
character  of  the  malady  with  which  it  happens  to  be  combined. 
Indeed,  instead  of  being  a  secondary  inflammation,  it  is  oftener, 
to  speak  correctly,  a  local  expression  of  a  constitutional  state. 

Several  writers  describe  a  form  of  gastritis  which  occurs  in  very 
young  children  and  leads  to  softening  of  the  mucous  lining  of 
the  stomach.  Jaeger,  Cruveilhier,  and  Billarcl  in  particular  have 
made  this  acute  gastric  softening  the  subject  of  study.  Yet  it  is 
very  doubtful  if  it  be  anything  more  than  a  post-mortem  result 
in  those  who  have  had  severe  gastric  catarrh.  The  symptoms 
ascribed  to  the  malady  are  exactly  like  those  of  acute  inflammation 
of  the  stomach.  As  I  have  no  experience  in  this  strange  disorder, 
I  shall  follow  the  delineation  given  of  it  by  Billard.* 

The  disease  usually  begins  with  tension  of  the  epigastric  region, 
which  is  painful  to  the  touch ;  with  vomiting,  not  only  of  the 
milk  and  of  the  other  liquids  swallowed,  but  also  of  a  green  or 
yellow  fluid.  This  vomiting  happens  either  immediately  or  some 
time  after  the  child  has  taken  food  or  drink.  There  is  occasion- 
ally diarrhoea ;  and  the  discharges  from  the  bowels  are  frequently 
greenish,  resembling  those  from  the  stomach.     The  respiration  is 

*  Maladies  des  Enfants  nouveau-nes. 


512  MEDICAL   DIAGNOSIS. 

hurried  and  jerking ;  the  extremities  are  cold  ;  the  face  and  cry 
are  -expressive  of  suiiering  ;  the  agitation  is  great.  To  this  state 
succeeds  "one  of  general  prostration  and  insensibility,  and  at  the 
end  of  six,  eight,  or  fifteen  days  the  patient  dies  exhausted,  from 
want  of  sleep  and  from  the  constant  vomiting  and  pain.  In  very 
young  children  there  is  hardly  any  fever.  The  disease  sometimes 
runs  a  more  chronic  course.  It  may  be  combined  with  a  similar 
softening  of  the  intestines.  Cruveilhier  has  seen  it  occur  in  epi- 
demics. He  describes  a  prodromic  period,  marked  by  rapid  loss 
of  strength,  and  by  intense  thirst.  Kundrat  has  called  attention 
to  the  occurrence  of  gastric  softening  with  vomiting  of  blood  in 
the  brain  affections  of  children,  especially  in  tubercular  meningitis. 

Chronic  Diseases  attended  with  Pain,  Epigastric  Tenderness,     - 
and  Vomitinr/. 

The  chronic  diseases  of  the  stomach  may,  like  the  acute,  be 
considered  in  accordance  with  the  pain,  the  soreness  at  the  epigas- 
trium, and  the  vomiting  that  attend  them.  At  all  events,  these 
are  the  symptoms  common  to  the  chronic  diseases  which  are  sus- 
ceptible of  diagnosis.  Besides  these,  there  are  some  chronic  dis- 
orders-with  the  morbid  anatomy  of  which  recent  careful  researches 
have  made  us  familiar, — such  as  destruction  of  the  tubular  struc- 
tures ;  hypertrophy  of  the  solitary  glands ;  interstitial  growths 
leading  to  glandular  wasting,  and  to  a  gradual  fibroid  thickening 
of  the  entire  mucous  or  submucous  coat ;  fatty  degeneration  of 
the  atrophied  masses,* — but  which  we  are  as  yet  unable  to  dis- 
tinguish at  the  bedside,  and  which,  so  far  as  has  been  ascertained, 
may  even  be  entirely  latent. 

Contrasting  the  chronic  diseases  with  which  we  are  clinically 
acquainted  with  the  acute,  vomiting  is  found  to  be  a  symptom  of 
greater  diagnostic  value, — not  the  act  itself,  but  the  appearances 
of  the  ejected  matter.  And,  further,  the  phenomena  of  dyspepsia 
stand  forth  much  more  conspicuously. 

Chronic  Gastritis. — In  chronic  inflammation  of  the  mucous 
membrane,  or  chronic  gastric  ccdarrh,  the  symptoms  of  indiges- 
tion are  persistent  and  manifold.    They  vary  somewhat  according 

*  See  Handfield  Jones,  Pathological  and  Clinical  Observations  respecting 
Morbid  Conditions  of  the  Stomach  ;  "Wilson  Fox,  Diseases  of  the  Stomach, 
1872;  and  Ewald,  o;).  ci7.,  1889. 


DISEASES   OF   THE   STOMACH.  513 

to  the  extent  of  the  mucous  surface  involved  and  the  amount  of 
mucus  and  epithelium  which  accumulates  on  it,  and  probably  also 
according  to  the  healthy  or  wasted  state  of  tlie  gastric  glands. 
Generally  there  is  a  sensation  of  discomfort,  of  weight,  and  of 
soreness  at  the  pit  of  the  stomach,  aggravated  by  food ;  the  part 
is  also  tender  to  the  touch.  Sometimes,  even  when  the  stomach 
is  empty,  a  burning  at  the  epigastrium  and  an  inward  fever  are 
complained  of.  The  appetite  is  impaired  or  capricious.  Fer- 
mentation, heart-burn,  and  flatulency  frequently  attend  the  slow 
digestion  of  the  food ;  the  tongue  is  usually  heavily  coated ;  it 
may,  however,  be  clean.  The  bowels  are  constipated.  The  urine 
contains  an  excess  of  phosphates  or  urates,  or  exhibits  crystals  of 
oxalate  of  lime.  The  patient's  circulation  is  languid ;  he  suffers 
from  chilliness ;  his  spirits  are  depressed.  Not  unfrequently  he  is 
annoyed  by  thirst,  and  by  vomiting,  after  meals,  the  half-digested 
food  mixed  with  strings  of  mucus.  But  the  vomiting  may  also 
take  place  when  the  stomach  is  empty,  and  the  ejected  matter  is 
then  fluid  and  colorless.  Drunkards  who  suffer  from  chronic 
gastritis  often  throw  up  a  quantity  of  glairy  fluid  on  rising  in 
the  morning.  A  colorless  vomit,  joined  to  symptoms  of  long- 
continued  indigestion,  is  very  characteristic  of  chronic  gastritis. 

Thus,  then,  the  character  of  the  vomit  occasionally,  more  fre- 
quently the  coated  tongue,  the  distress  after  eating,  the  soreness 
at  the  epigastrium,  and  the  persistency  of  the  symptoms,  distin- 
guish the  dyspepsia  of  chronic  inflammation  of  the  stomach  from 
that  which  is  purely  functional. 

The  causes  of  the  malady  are  at  times  obscure.  It  certainly 
cannot  be  traced  often  to  an  antecedent  acute  attack,  although 
those  who  suffer  from  the  chronic  disorder  are  particularly  prone 
to  acute  exacerbations.  It  is  more  common  in  persons  over  than 
in  those  under  forty  years  of  age.  It  is  especially  common  in 
gourmands  and  drunkards,  and  in  those  who  live  on  coarse  food. 
It  is  often  found  conjoined  with  chronic  bronchitis,  and  sometimes 
with  tubercular  disease  of  the  lungs,  or  with  amyloid  degeneration. 
Passive  congestion  undoubtedly  acts  as  a  predisposing  element. 
The  inflammation  is  seen  to  arise  from  this  cause  in  the  course  of 
chronic  affections  of  the  heart,  of  the  liver,  and  of  obstructions 
to  the  portal  circulation,  whether  complicated  with  a  lesion  of  the 
liver  or  not. 

33 


514  MEDICAL   DIAGNOSIS. 

Chronic  gastritis  is  frequently  associated  with  ulcers  in  the  organ 
or  with  cancer,  and  many  of  the  symptoms  of  these  disoi;ders  are 
clearly  attributable  to  it.  Let  us  inquire  whether  there  are  any 
special  symptoms  to  inform  us  that  something  more  dangerous 
than  chronic  inflammation  of  the  mucous  membrane  of  the  stom- 
ach exists. 

Gastric  Ulcer. — Ulcer  of  the  stomach  is  a  disease  compara- 
tively rare  in  this  country ;  but  it  is  not  so  in  some  parts  of  the 
Continent  of  Europe  and  in  England.  It  is  generally  associated 
with  ana;mia,  or  follows  chronic  gastric  catarrh,  or  embolic  plug- 
ging of  small  arterial  twigs,  or  other  disturbances  of  the  circu- 
lation in  the  gastric  mucous  membrane.  Amyloid  degeneration 
of  the  finer  vessels,  too,  occasions  these  perforating  ulcers.  The 
acid  gastric  juice  acts  readily  and  destructively  on  the  weakened 
tissues. 

The  ulcer  or  ulcers,  for  there  are  sometimes  several  present, 
are  seated  most  usually  on  the  posterior  wall  of  the  stomach,  in 
or  near  the  lesser  curvature  and  toward  the  pyloric  extremity. 
The  great  danger  arises  from  perforation  of  the  coats  and  subse- 
quent peritonitis.  But  the  ulceration  may  prove  fatal  by  opening 
a  large  blood-vessel.  Again,  the  formation  of  a  gastro-colic  or 
a  gastro-pulmonary  fistula  may  lead  to  death ;  or  the  protracted 
sufiering  and  excessive  vomiting  may  gradually  exliaust  the  vital 
energies.  On  the  other  hand,  the  ulcers  may  heal  by  cicatrization ; 
and  this,  "William  Brinton  tells  us,  takes  place  in  about  half  the 
instances.     Recurrence  of  the  affection  is  not  uncommon. 

In  cases  which  may  be  regarded  as  typical,  the  malady  is  an- 
nounced by  symptoms  exactly  like  those  witnessed  in  chronic 
gastritis, — the  same  uneasiness  and  pain  at  the  epigastrium,  and 
occasional  nausea  and  vomiting  of  food,  or  of  a  watery  fluid. 
Perforation  may  at  this  early  stage  of  the  disease  most  unex- 
pectedly cut  short  the  patient's  life.  Should  perforation  not 
take  place,  hemorrhage  from  the  stomach,  with  emaciation  and 
anjemia,  next  appears.  In  this  way  the  disease  usually  continues 
for  months  or  years,  the  symptoms  remitting  from  time  to  time, 
and  showing  singular  variations  in  their  severity.    Welch*  states 


*  Pepper's   System   of  Practical   Medicine,  article   •'  Simple  Ulcer   of  the 
Stomach." 


DISEASES   OP^   THE   STOMACH.  515 

the  average  duration  of  gastric  ulcer  to  be  from  three  to  five 
years.     The  majority  of  the  cases  recover. 

Of  the  symptoms,  pain  and  vomiting  are  the  most  character- 
istic. Pain  is  rarely  absent ;  never,  perhaps,  except  in  cases  which 
run  a  rapid  course.  It  is  generally  a  continuous  dtdl  feeling; 
sometimes  a  burning,  at  other  times  a  gnawing  sensation.  As  a 
rule,  it  is  rendered  more  acute  within  a  quarter  of  an  hour  after 
eating,  and  remains  so  as  long  as  food  occupies  the  stomach.  Its 
situation  is  commonly  in  the  middle  of  the  epigastric  region,  and 
there  it  continues  strictly  limited.  At  that  point,  too,  there  is 
localized  soreness,  or  even  great  tenderness  to  the  touch.  Some- 
times the  pain  is  seated  behind  the  ensiform  cartilage,  or  is 
referred  to  the  right  or  to  the  left  hypochondrium.  It  is  often 
associated  with  a  gnawing  pain  in  the  lower  dorsal  vertebrae, 
which  may  shoot  between  the  scapulae  or  down  the  spine  ;  but 
the  dorsal  pain,  like  the  epigastric,  is,  on  the  whole,  very  fixed, 
radiates  but  little,  and  is  most  severe  when  the  ulcer  is  on  the 
posterior  surface.  Besides  this  continued  feeling  of  distress,  there 
occur  violent  paroxysms  of  pain,  which  may  last  for  several  hours ; 
nay,  with  trifling  intermissions,  for  days.  They  sometimes  come 
on  suddenly  when  the  viscus  is  empty,  but  are  aggravated  by 
pressure  or  by  food ;  and,  in  fact,  they  are  often  thus  induced. 
The  patient  refers  the  suffering  chiefly  to  the  pit  of  the  stomach, 
or  to  the  dorsal  vertebrse.  He  is  apt  to  seek  the  recumbent  posture 
for  its  relief.  Yet  it  is  remarkable  that  there  are  at  times  long 
intervals  during  which  all  pain,  whether  paroxysmal  or  not,  ceases, 
and  during;  which  food  can  be  taken  without  inconvenience. 

The  peculiarities  the  pain  exhibits  form,  on  the  whole,  the 
most  distinctive  symptom  of  gastric  ulceration.  The  paroxysms 
just  spoken  of  might  be  mistaken  for  a  purely  nervous  gastralgia. 
Indeed,  when  it  is  considered  that  both  disorders  are  specially  apt 
to  occur  in  anaemic  women,  and  in  those  whose  menstrual  func- 
tions are  deranged,  it  becomes  apparent  hoAV  easily  this  mistake 
may  be  committed.  The  soreness  at  the  epigastrium  ;  the  per- 
sistent symptoms  of  indigestion ;  the  excess  of  hydrochloric  acid 
in  the  gastric  juice  ;  the  increase  of  pain  after  meals, — constitute, 
in  a  diagnostic  point  of  view,  the  safeguard  against  error.  To 
these  might  be  added  the  vomiting  of  blood,  were  it  not  that 
vicarious  hemorrhages  are  not  at  all  unlikely  to  take  place  in 


516  MEDICAL   DIAGNOSIS. 

young-  -women  who  arc  troubled  witli  anienorrhoca.  This  is,  in 
triith,  a  matter  having-  a  close  connection  -with  the  diagnosis  of 
gastric  ulceration.  Persons  who  suffer  from  disturbance  of  the 
menstrual  function  arc  prone  to  be  hysterical ;  and  it  may  happen 
that  one  of  the  most  marked  traits  of  the  hysterical  disorder  is 
that  it  manifests  itself  by  tenderness  in  the  epigastric  region,  and 
by  pain  in  the  stomach. 

We  thus  may  have  the  most  significant  signs  of  gastric  ulcer, 
occurring,  as  so  many  cases  of  amenorrha?a  do,  in  chlorotic  young 
\\omen ;  therefore  hai3pening-  in  the  class  among-  whom  ulceration 
of  the  stomach  is  most  frequent.  Nay,  the  very  history  may  point 
to  the  probability  of  gastric  ulcer.*  Yet  generally,  by  close  atten- 
tion to  all  the  phenomena  of  the  case,  we  can  arrive  at  a  correct 
conclusion.  The  tenderness,  as  in  all  local  hysterical  affections, 
is  great  on  the  slightest  touch ;  and  there  is  no  severe  pain  pos- 
teriorly corresponding  to  the  spot  of  soreness  in  the  epigastric 
region.  Pressure  upon  a  spinous  process  may  cause  pain,  but  it 
is  not  the  peculiar  dorsal  pain  of  gastric  ulceration.  Then,  in  the 
hysterical  complaint  there  is  often  hyperesthesia  of  the  skin  in 
various  portions  of  the  body,  and  the  apparent  gastric  distress 
bears  no  relation  to  the  taking  of  food  or  to  the  circumstance  of 
its  being  of  an  irritating  character  or  otherwise.  The  epigastric 
surface  temperature  is  elevated  in  gastric  ulcer,  and  may  even 
exceed  the  temperature  in  the  axilla.f 

But  to  return  to  the  vomiting  of  blood.  When  this  is  not 
traceable  to  a  suppression  of  a  natural  discharge,  and  when  it 
does  not  befall  a  person  who  suffers  from  disease  of  the  heart,  or 
liver,  or  spleen,  or  oesophagus,  it  acquires  great  significance.  It 
is  the  only  kind  of  vomit  at  all  distinctive  of  a  gastric  ulcer ;  for 
the  substances  ejected  present  otherwise  appearances  not  different 
from  what  they  do  in  chronic  gastritis.  The  blood  may  be  pure 
and  red,  but  it  is  more  frequently  blackened  by  the  gastric  juice  y 
and  large  quantities  are  sometimes  passed  by  stool.  Now,  hem- 
orrhage does  not  take  place  in  chronic  inflammation  of  the  mucous 
membrane  of  the  stomach,  except  perhaps  in  drunkards.  In  those 
instances  in   which  erosions  exist  on  the  surface,  the  vomited 


*  Case  under  my  care,  Philadelphia  Hospital ;  Med.  and  Surg.  Kep.,  Feb.  1863. 
t  Hayem,  Kevue  des  Sciences  Medicales,  Oct.  15,  1888. 


DISEASES   OF   THE   STOMACH.  517 

mucus  may  be  a  little  streaked  with  blood ;  yet  anything  like 
a  profuse  hemorrhage  never  happens.  Hence  its  occurrence  in  a 
case  with  the  symptoms  of  chronic  gastritis,  cancer  being  excluded, 
renders  the  presence  of  an  ulcer  probable. 

The  vomiting  of  the  matters  taken  into  the  stomach  may  be 
immediate  or  not  for  some  time  after  the  food  has  been  swallowed. 
Usually  it  happens  speedily,  and  in  some  instances  so  speedily 
that  there  seems  to  be  rather  regurgitation  than  vomiting.  But 
this  is  rare,  and  in  the  rarity  is  a  safeguard  against  confounding 
gastric  ulcer  with  the  vomiting  of  cerebral  disease,  especially 
tumor;  which  I  have  known  to  happen  in  a  young  woman  in 
whom,  moreover,  vomiting  of  blood  had  occurred.  In  the  re- 
gurgitation, then,  in  the  frequently  absent  nausea,  in  the  clean 
tongue, — though  coating  may  also  be  absent  in  ulcer, — in  the  want 
of  oppression  and  weight  at  the  epigastrium,  and  in  the  headache, 
altered  vision,  and  other  nervous  phenomena,  we  have  the  distin- 
guishing traits  between  gastric  and  cerebral  vomiting  on  which 
to  lay  stress  in  the  diagnosis  between  disease  of  the  brain  and 
gastric  ulcer,  or  indeed  any  other  serious  stomach  affection. 

In  concluding  this  sketch  of  gastric  ulceration,  two  questions 
arise  which  require  solution  :  Does  an  ulcer  always  produce  the 
peculiar  train  of  sjmptoms  mentioned ?  May  not  the  same  phe- 
nomena be  met  with  in  other  disorders  ?  The  first  question  must 
be  answered  in  the  negative.  Ulceration  of  the  stomach  may 
occasion  nothing  but  the  symptoms  of  chronic  gastritis  ;  and  even 
these  may  not  be  marked.  The  second  question  is  to  be  answered 
in  the  affirmative.  There  is  a  disorder  with  symptoms  almost 
identical  with  those  of  gastric  ulcer,  the  corrosive  ulcer  of  the 
duodenum.  Now,  this  affection,  were  it  more  frequent,  would  be 
a  constant  source  of  error.  It  may  run  an  acute,  or  at  least  an 
apparently  acute,  or  a  chronic  course.  In  either  c^se  it  is  scarcely 
distinguishable  from  gastric  ulceration.     Trier,*  from  an  analysis 


*  Quoted  in  British  and  Foreign  Medico-Chirurgical  Keview,  Feb.  1864. 
See,  also,  the  excellent  monograph  by  Krauss,  "  Das  perforirende  Geschwiir 
im  Duodenum,"  1865,  and  remarks  on  it  in  Niemeyer's  work  on  Practical 
Medicine;  Wadham  and  Barclay,  London  Lancet,  Feb.  and  March,  1871 ; 
G.  OUive,  G-az.  Med.  de  Kantes,  1885-86,  iv.  31 ;  W.  Osier,  Canada  Med.  and 
Surg.  Journ.,  Montreal,  1886-87,  xv. ;  Bucquoy,  Arch.  Gen.  de  Med.,  Dec.  1887  ; 
W.  H.  Allchin,  Transact.  Pathol.  Soc.  Lond.,  1887,  xxxviii.  ;  Schrotter,  Aerzt- 


518  MEDICAL   DIAGNOSIS. 

of  twenty-six  cases,  mentions,  as  the  most  important  grounds  for 
a  differential  diagnosis,  signs  of  dilatation  of  the  stomach ;  a  sen- 
sitive tinuor  in  the  epigastrium,  proceeding  from  adhesion  with 
ihv  pancreas;  and  jaundice  or  other  hepatic  phenomena.  But 
these  symptoms  are  iar  from  constant ;  and,  in  accordance  with 
his  own  showing,  in  acute  cases,  and  in  those  chronic  cases  which 
run  a  latent  course,  the  diagnosis  is  impossible.  It  may  be  added 
that  the  perforating  ulcer  of  the  duodenum  is  much  more  apt  than 
idcer  of  the  stomach  to  remain  latent  and  to  lead  suddenly  to  a 
fatal  termination.  Duodenal  ulcer  is  thought  by  some  to  be  al- 
most invariably  due  to  the  action  of  a  highly-acid  gastric  juice, 
and  to  furnish  the  best  illustration  of  the  so-called  "  peptic  ulcer." 
It  is  most  common  between  thirty  and  forty  years  of  age,  and,  as 
Krauss  proves,  is  ten  times  more  common  in  men  than  in  women. 

There  is  yet  another  affection  with  symptoms  like  those  of  ulcer, 
an  affection  still  more  serious  and  destructive, — cancer. 

Gastric  Cancer. — Cancer  is  found  more  frequently  in  the 
stomach  than  in  any  other  organ  except  the  uterus.  Of  nine 
thousand  one  hundred  and  eighteen  cases  of  cancer  which  occurred 
in  Paris  from  1837  to  1840,  two  thousand  three  hundred  and  three 
were  in  the  stomach.*  The  disease  is  generally  primary.  It  is 
most  often  seated  at  the  pylorus ;  next  in  frequency  stands  the 
cardiac  orifice  ;  most  rarely  does  it  involve  the  whole  viscus.  We 
find  all  the  varieties  of  cancer  affecting  the  stomach  ;  but  none 
is  so  common  as  scirrhus.  Indeed,  what  is  called  cancer  of  the 
stomach  means,  in  the  large  majority  of  cases,  scirrhus ;  and,  more- 
over, scirrhus  at  the  pyloric  extremity,  deposited  primarily  in  the 
textures  which  intervene  between  the  mucous  and  the  serous  coat. 
It  would  be  out  of  place  to  enter  here  into  a  minute  description 
of  the  appearances  of  a  gastric  scirrhus.  I  shall  only  state  that 
I  have  usually  found  it  to  present  cell-growths  less  marked  than 
those  of  scirrhus  of  any  other  part  of  the  body.  As  found  by  an 
analysis  of  two  thousand  and  thirty-eight  cases  of  gastric  cancer, 
three-fourths  occur  between  forty  and  seventy  years  of  age.f 

licher  Bericht  des  k.  k.  Allgemeinen  Krankenhauses  zu  ~\Vien  (1886),  1888,  27  ; 
J.  M.  Emmert,  Weekly  Med.  Rev.,  St.  Louis,  1888,  xviii.  ;  W.  W.  Johnston, 
Amer.  Journ.  Med.  Sci.,  1888,  IS".  S.,  xcvi. 

*  Walshe  on  Cancer. 

f  AVelch,  Pepper's  System  of  Practical  Medicine. 


DISEASES   OF   THE   STOMACH.  519 

The  symptoms  of  cancer  of  the  stomach  are  the  same  as  those 
of  chronic  gastritis, — pain,  tenderness  in  the  epigastrium,  disor- 
dered digestion,  vomiting.  In  a  more  advanced  state  of  the  can- 
cerous malady  they  may  be  those  of  gastric  ulcer,  hemorrhage 
being  added  to  the  list  above  given.  There  is  only  one  symptom 
at  all  distinctive  of  cancer, — namely,  the  existence  of  a  tumor; 
and  this  is  so  only  when  it  is  joined  to  digestive  disorder  and  to 
increasing  anorexia,  debility,  and  emaciation. 

But  let  us  see  if  there  be  anything  in  the  pain  and  vomiting, 
or  in  the  circumstances  of  the  case,  by  which,  even  when  a  tumor 
cannot  be  discovered,  the  presence  of  a  cancer  may  be  suspected. 
Pain  is  a  very  constant  symptom ;  quite  as  constant  as  in  gastric 
ulcer.  But  the  pain  is,  as  a  rule,  more  continued,  much  less  in- 
fluenced by  the  taking  of  food,  and  more  radiating,  being  often 
referred  to  the  right  or  the  left  hypochondrium.  Its  character  is 
very  varying.  It  may  be  dull,  or  gnawing,  or  it  may  be  lanci- 
nating. It  may  be  slight,  or  it  may  amount  to  excruciating 
agony.  It  is  often  of  the  latter  kind.  But  it  is  a  mistake  to 
suppose  that  a  cancer  of  the  stomach  necessarily  causes  severe 
or  lancinating  pain.  Again,  it  should  be  borne  in  mind  that  the 
part  diseased  may  ulcerate,  and  then  the  pain  is  exactly  like  that 
of  an  ordinary  gastric  ulcer,  and  is  affected  in  the  same  way  by 
food. 

Vomiting  is  not  an  invariable  result  of  cancer;  yet  it  is  a 
frequent  one.  The  seat  of  the  morbid  growth  determines,  to  a 
great  extent,  the  occurrence  of  vomiting  and  the  period  at  which 
it  will  happen.  When  the  body  of  the  stomach  is  attacked,  and 
the  orifices  are  not  obstructed,  it  may  not  take  place  at  all ;  or, 
if  it  take  place,  it  is  within  a  brief  time  after  meals.  When  the 
disease  has  narrowed  the  cardiac  extremity,  vomiting  supervenes 
almost  immediately ;  the  food  has  hardly  been  swallowed  before 
it  is  brought  up  again.  But  when,  as  Js  much  more  common, 
the  pylorus  is  constricted,  the  food  is  not  thrown  off  until  it 
attempts  to  pass  through  into  the  intestine ;  therefore  not  until  a 
considerable  time  after  meals. 

With  respect  to  the  character  of  the  substances  ejected,  this  too 
depends  on  the  seat  of  the  cancer,  and  the  time  at  which  the  vomit- 
ing arises.  If  it  ensue  several  hours  after  meals,  the  cast-off  matter 
consists  of  food  partly  digested,  partly  in  a  state  of  highly-acetous 


520  MEDICAL   DIAGNOSIS. 

fermentation.  An  enormous  quantity  of  acid  material,  the  accumu- 
lation of  several  meals,  is  sometimes  brought  up  during  one  act  of 
emesis.  The  ejected  matter  may  be  intermingled  with  blood,  and 
have  a  blackish  or  reddish-brown,  "coffee-ground"  appearance; 
or  the  mucus  which  is  thrown  up  may  be  tinged  with  black  flakes  : 
in  either  case  we  find  reduced  hsematin.  It  is  rare  that  any  con- 
siderable amount  of  unmixed  blood  is  vomited. 

Free  hydrochloric  acid  is,  as  discovered  by  von  den  Velden,* 
absent  in  the  vomited  contents  of  the  stomach  or  in  the  "  trial 
meal."  But  we  must  not  forget  that  it  is  also  absent  in  amyloid 
degeneration,  in  dilatation  of  the  stomach  with  narrowed  pylorus, 
in  many  fevers,  and  occasionally  in  chronic  gastritis.  Its  constant 
absence  bespeaks  cancer.  The  test  is  best  made  in  the  manner 
already  described. 

A  close  study  of  the  pain  and  vomiting  may  furnish  evidence 
by  which  the  existence  of  a  gastric  cancer  may  be  suspected. 
There  are  a  few  other  circumstances  Avhich  would  strengthen  this 
suspicion :  one  of  these  is  the  intense  acidity  of  the  stomach,  with 
the  sour  eructations;  another,  the  extreme  flatulency;  another, 
the  fetid  breath,  for  althoagh  fetor  of  the  breath  n^ay  result  from 
putrefactive  changes  in  the  food  in  almost  any  form  of  gastric 
disorder,  it  is  never  perhaps  so  permanent  as  in  cancer.  A  fourth 
is  the  obstinate  constipation  ;  a  fifth,  the  progressive  loss  of  flesh 
and  the  cachectic  appearance  of  the  patient,  who  is  pale  and  tired- 
looking,  or  has  a  complexion  slightly  jaundiced,  or  whose  face  is 
of  a  color  which  seems  to  have  arisen  from  a  combination  of  the 
hue  of  chlorosis  and  that  of  jaundice.  The  supposed  characteristic 
straw  color  of  cancer  is  not  often  met  with.  The  temperature  is 
generally  below  the  norm  ;  but  there  are  exceptional  cases  in  which 
a  moderate  amount  of  irritative  fever  accompanies  the  gradual 
wasting, — gradual,  because  the  duration  of  the  malady  averages 
more  than  a  year.  CEdema  of  the  ankles  is  a  frequent  symptom 
of  the  advancing  disease.  In  some  instances  coma  hajjpens  similar 
to  diabetic  coma. 

Now,  should  all  these  symptoms  be  met  with  in  a  person  who 
is  steadily  becoming  feebler,  whose  age  is  above  forty,  in  whose 
family  cancer  is  hereditary ;   should   cancerous   tumors  develop 

*  Deutsches  Arch.  f.  Klin.  Med.,  Bd.  xiii. 


DISEASES   OP   THE   STOMACH. 


521 


themselves  in  any  other  part  of  the  body, — the  suspicion  enter- 
tained would  be  converted  into  almost  a  certainty.  But  it  is  not 
often  that  a  perfectly  typical  case,  presenting  a  combination  of  all 
the  symptoms  enumerated,  is  met  with.  And,  I  repeat,  the  most 
distinctive  sign  is  a  tumor :  when  this  is  not  detected,  consider- 
able uncertainty  hangs  over  any  diagnosis  of  gastric  cancer. 

To  contrast,  then,  cancer  of  the  stomach  with  chronic-  gastritis 
and  gastric  ulcer : 


Chronic  Gastritis. 

Pain  at  the  epigastrium  some- 
,what  augmented  by  food; 
also  soreness.  Both  con- 
stant, although  compara- 
tively slight. 


Symptoms 
marked. 


of       indigestion 


Sometimes  vomiting. 

No  hemorrhage,  or  but  trifling 
hemorrhage ;  at  most,  blood- 
streaks  in  vomited  matter. 

Bowels  constipated. 

No  fever. 


Not  much  emaciation ; 
chectic  appearance. 


Not  confined  to  any  age.  More 
common  in  middle-aged  or 
elderly  people. 

Disease  may  be  relieved  or 
cured ;  is  often  of  very  long 
duration. 

No  tumor. 

Contents  of  stomach  contain 
almost  always  free  hydro- 
chloric acid. 

No  dropsy. 


Gastric  Ulcer. 

Pain  at  the  epigastrium  much 
augmented  by  food  ;  subsides 
when  this  is  digested  ;  paro.x- 
ysms  of  pain,  but  not  lanci- 
nating; a  strictly-localized 
soreness  to  the  touch  in  the 
epigastric  region,  sometimes 
a  painful  spot  over  the  lower 
dorsal  vertebrte.  Intermis- 
sions in  the  pain  of  consider- 
able length  are  frequent. 

Symptoms  of  indigestion  some- 
times very  slight. 

Vomiting    may   be  present   or 

absent. 
Abundant     hemorrhage     from 

the  stomach  common. 


Bowels  may  or  may  not  be  con- 
stipated ;  usually  are. 
No  fever. 


Frequently  extreme  pallor  and 
debility. 


May  occur  in  middle-aged  per- 
sons ;  but  is  most  frequently 
seen  in  young  adults,  espe- 
cially in  young  women. 

Duration  uncertain ;  may  get 
well,  may  run  on  rapidly  to 
perforation;  on  the  other 
hand,  may  last  for  years. 

No  tumor. 

Hydrochloric  acid  in  excess  in 
contents  of  stomach. 

No  dropsy. 


Gastric  Cancrr. 

Pain  frequently  of  a  radiating 
kind,  often  paroxysmal,  nut 
unusually  severe  and  lanci- 
nating, but  not  of  necessity 
associated  with  soreness.  Lit- 
tle or  not  at  all  affected  by 
food.  Pain  rarely  remits ; 
never  intermits  for  any  con- 
siderable time. 


Symptoms  of  indigestion 
marlied.  Anorexia ;  extreme 
acidity  of  stomach. 

Vomiting  a  very  frequent 
symptom. 

Hemorrhage  not  very  abun- 
dant, but  occasioning  fre- 
quently coffee-ground-look- 
ing  vomit. 

Bowels  obstinately  constipated. 

Intercurrent  attacks  of  slight 
fever  may  occur ;  but  temper- 
ature often  subnormal. 

Gradual  and  pi'ogressive  loss  of 
flesh,  and  debility ;  and  at 
times  with  the  cachexia  hy- 
pertrophy of  the  peripheral 
lymphatic  glands,  especially 
above  the  clavicles. 

Most  common  in  elderl3'  peo- 
ple ;  rarely  occurs  in  persons 
under  forty  years  of  age. 

Average  duration  one  year; 
may  be  shorter,  but  seldom 
longer;  very  rarely  reaches 
two  years. 

Generally  a  tumor. 

No  hydrochloric  acid  in  con- 
tents of  stomach. 

(Edema  of  ankles  often  met 
■with. 


522  MEDICAL   DIAGNOSIS. 

The  differences  laid  down  in  the  table  are  derived  from  an 
analysis  of  well-marked  eases.  In  the  early  stages  of  the  eancer- 
ons  malady,  a  ditterential  diagnosis  is  impossible.  Snbseqnently, 
as  already  stated,  the  detection  of  a  tumor  plays  an  important 
part  in  any  deduction.  But  this  remark  does  not  apply  to  cases 
of"  cancer  of  the  cardiac  orifice,  which  are  rare,  and  in  which  a 
tumor,  from  its  deep  situation,  almost  always  eludes  discovery. 
Such  cases  are,  however,  discriminated  by  their  presenting  the 
same  signs  as  a  stricture  of  the  oesophagus  low  down ;  indeed, 
they  are  very  constantly  combined  with  a  narrowing  of  the  tube, 
produced  by  the  cancer  spreading  to  it.  Cancer  at  other  parts  of 
the  organ  occasions  a  perceptible  tmnor  in  about  three-fourths  of 
all  the  instances ;  its  situation  is,  of  course,  not  always  the  same. 
Where  no  tumor  can  be  discerned,  and  particularly  if,  as  may 
happen,  portions  of  the  stomach  remain  healthy  and  the  digestive 
disturbances  are  slight,  the  existence  of  cancer  may  not  reveal 
itself  by  any  symptoms,  and  the  case  run  a  latent  course.* 

A  cancer  of  the  anterior  wall  produces,  as  a  rule,  fulness,  re- 
sistance, and  percussion  dulness  in  the  epigastric  region.  A  can- 
cer involving  the  greater  curvature  gives  rise  to  a  swelling  near 
the  umbilicus,  or  to  one  extending  toward  either  hypochondrium. 
The  tumor  formed  by  cancer  of  the  pylorus  is  commonly  felt 
plainly  a  little  to  the  right  of  the  median  line,  and  one  to  two 
inches  below  the  cartilages  of  the  ribs.  In  women  its  position 
is  apt  to  be  even  lower  than  this ;  and,  indeed,  in  both  sexes  the 
situation  of  the  indurated  pylorus  is  very  variable.  It  may  be 
pushed  down  to  near  the  umbilicus ;  nay,  it  has  been  discerned 
near  the  anterior  superior  spinous  process  of  the  ilium.f  It  is 
rarely  found  in  the  left  hypochondrium,  but  not  unfrequently 
in  the  right.  Then  it  may  form  adhesions  to  the  liver,  which 
viscus  at  times  so  completely  covers  the  tumor  as  to  render  this 
impossible  of  detection. 

The  reason  why  the  swelling,  in  not  a  few  instances,  shows 
itself  much  lower  than  the  normal  scat  of  the  pylorus,  is  obvious. 
During  meal  after  meal  the  organ  seeks  to  overcome  the  resistance 


*  See  report  of  case  under  my  care  at  the  Pennsylvania  Hospital,  published 
in  Amer.  -Journ.  of  Med.  Sci.,  vol.  lii.,  1866. 

t  See  Lebert's  cases  in  Traite  pratique  des  Maladies  cancereuses. 


DISEASES   OF   THE   STOMACH.  523 

offered  by  the  narrowed  pyloric  orifice,  and  does  so  with  great 
and  increasing  difficulty.  The  constantly-repeated  and  long- 
continued  struggle  leads  to  hypertrophy  of  the  muscular  coat 
and  to  distention  of  the  hollow  viscus. 

The  tumor  may  or  may  not  be  movable, — generally  is  not; 
its  surface  may  be  either  smooth  or  nodulated.  It  may  be  large 
and  distinct,  or  small  and  requiring  a  careful  examination  to 
distinguish  it  from  the  surrounding  and  more  yielding  textures. 
Percussing  over  it  elicits  a  dull  sound,  usually  mixed  with  a 
tympanitic  note.  The  tumor  is  much  more  perceptible  on  some 
days  than  it  is  on  others.  Its  existence,  as  has  been  already 
insisted  on,  furnishes  the  most  conclusive  evidence  in  favor  of  a 
cancer. 

But  is  a  swelling  in  the  region  of  the  stomach  strictly  pathog- 
nomonic of  gastric  cancer  ?  No  ;  not  even  when  the  swelling  has 
been  ascertained  to  belong  to  that  viscus.  A  mere  fibroid  thicken- 
ing of  the  pylorus  will  occasion  a  tumor,  and,  moreover,  produce 
symptoms  which  resemble  so  closely  those  of  malignant  disease 
at  the  orifice,  that  I  much  doubt  the  possibility  of  distinguishing 
during  life,  with  any  certainty,  between  the  two  affections.  Let 
us  take  this  case,  which  I  saw  with  Dr.  Moss,*  as  an  example. 

A  woman,  aged  forty,  complained  much  of  pain  at  the  pit  of 
the  stomach,  and  of  a  heavy  sensation  throughout  the  abdomen. 
For  some  months  she  had  been  suffering  from  indigestion,  and  had 
been  steadily  losing  flesh.  Her  countenance  had  a  tired  look,  and 
she  was  very  despondent.  She  had  a  slight  cough ;  and  on  per- 
cussing the  lungs,  impaii-ed  resonance  was  detected  at  the  apices. 
The  .bowels  were  obstinately  constipated,  the  tongue  was  smooth 
and  red,  the  pulse  feeble.  She  vomited  shortly  after  meals,  yet 
never  anything  but  the  ingesta.  There  was  no  pain  on  press- 
ure over  the  pylorus  ;  but  a  greater  resistance  to  the  finger  than 
usual  was  detected.  The  further  progress  of  the  complaint  was 
marked  by  incessant  vomiting,  only,  however,  after  meals.  Once, 
and  once  only,  did  it  cease  for  several  days ;  and  then  without 
apparent  cause.  As  the  case  drew  toward  its  fatal  termination, 
the  patient  was  much  troubled  with  acid  eructations,  and  had 
occasionally  slight  febrile  attacks.    The  distress  in  the  epigastrium 

*  Published  in  full  in  Froc.  of  Pathol.  Soc.  of  Phila.,  vol.  i. 


524  MEDICAL  DIAGNOSIS. 

increased  in  severity.  About  three  weeks  before  her  death  she 
was  seized  witli  hincinating  pains  under  both  patelhe,  whieh  were 
neither  relieved  nor  aggravated  by  pressure  or  motion.  Tliey  were 
accompanied  by  pricking  sensations  and  numbness  in  the  legs,  and 
an  inability  to  walk.  The  pains  gradually  ceased,  but  tlie  numb- 
ness and  loss  of  motion  increased  from  day  to  day.  She  died, 
utterly  exhausted  by  the  abdominal  pains  and  the  incessant  vomit- 
ing, about  three  months  after  she  began  to  reject  her  food.  On 
post-mortem  examination,  tubercular  deposits  were  found  at  the 
apices  of  the  lungs.  The  abdominal  viscera  were  healthy,  except 
the  stomach  ;  and  this,  too,  was  healthy,  save  at  its  pyloric  orifice, 
which  was  so  narrowed  that  the  tip  of  the  little  finger  could  hardly 
be  forced  into  it.  The  mucous  lining  lay  in  folds,  but  on  dis- 
section was  found  to  be  perfectly  normal.  At  the  pylorus,  but 
onlv  there,  the  submucous  and  the  muscular  coat  were  uniformly 
thickened.  Examined  microscopically,  they  contained  nothing 
but  areolar  tissue,  spindle-shaped  fibre-cells,  and  very  distinct 
organic  muscular  fibres. 

Now,  here  is  a  case  which  was  not  cancer ;  yet  it  had  the  symp- 
toms of  cancer.  It  is  true  that  the  absence  of  blood  and  of  glairy 
mucus  in  the  matter  vomited,  and  the  indistinctness  of  the  swell- 
ing, in  spite  of  the  great  emaciation,  were  against  the  supposition 
of  cancer  of  the  pylorus.  Still,  no  inference  based  on  these  data 
alone  could  be  strictly  trusted,  since  every  cancer  is  not  associated 
with  the  vomit  of  coifee-ground  material  or  of  glairy  mucus,  or 
with  a  palpable  tumor.  The  disease  was  combined  with  tuber- 
cular deposits  in  the  lung.  Nor  is  this  the  only  example  of 
the  combination  whicli  has  come  under  my  notice.  And  Avhen  a 
tubercular  state  of  the  lung  has  been  fairly  made  out,  and  there 
exist  at  the  same  time  signs  of  pyloric  obstruction,  I  should  make 
a  diagnosis  that  this  is  not  of  a  cancerous  nature,  but  consists 
simply  of  an  increased  development  of  the  submucous  coat,  with 
probably  subsequent  hypertrophy  of  the  muscular  tunic. 

The  fibroid  thickening  may  extend  throughout  the  whole  stom- 
ach. Such  cases  differ  from  cancer  by  their  long  duration  ;  the 
absence  of  hemorrhage,  of  vomiting,  and  of  severe  pain  ;  and  the 
more  uniform  gastric  swelling.  The  affection  is  sometimes  ob- 
served in  spirit-drinkers.  Its  discrimination  from  cancer  is  never 
a  certainty,  but  merely  a  matter  of  conjecture. 


DISEASES   OF   THE   STOMACH.  525 

There  are  other  diseases  than  those  of  the  stomach  which  may 
occasion  a  tumor  in  its  region,  and  are  thus  liable  to  be  mistaken 
for  o-astric  cancer.  Prominent  among  these  are  enlargement  of 
the  liver  projecting  into  the  epigastrium,  tumors  of  the  omentum, 
and  diseases  of  the  pancreas  and  of  the  kidney.  Of  course,  the 
stomach  symptoms  proper  are  not  so  marked  in  these  affections, 
and  in  some  they  may  be  wholly  wanting ;  examination  of  the 
urine  and  due  regard  to  the  history  of  the  case  will  show  us  the 
truth  about  the  others  ;  and,  after  all,  the  chief  way  of  preventing 
ourselves  from  falling  into  error  is  to  seek  in  any  case  of  supposed 
p-astric  cancer  for  these  other  diseases,  and  to  see  if  their  chief 
symptoms  be  present. 

Resting  with  this  general  statement,  I  shall  not  take  up  the 
differential  diagnosis  of  all  the  many  affections  mentioned ;  es- 
pecially as  some  are  referred  to  when  treating  of  partial  abdominal 
enlargements  and  of  cancer  of  the  liver.  But  there  are  two  which 
may  be  here  specially  looked  at :  one  is  omental  cancer,  the  other 
kidney  affection  attended  with  marked  swelling,  such  as  in  hydro- 
nephrosis, pyonephrosis,  abscess,  hydatids,  and  morbid  growths. 

In  omental  cancer  there  is  far  less  dyspepsia,  hemorrhage  and 
coffee-ground  vomit  are  absent,  the  tumor  appears  to  occupy 
chiefly  the  site  of  the  greater  curvature,  and  the  swelling  is,  or 
soon  becomes,  more  generally  diffuse. 

In  the  kidney  affections  referred  to,  the  history  is  of  great 
importance,  and  we  include  in  this  history  the  passage  of  renal 
calculi  as  bearing  on  some  forms  of  kidney  enlargement,  especially 
abscess  from  impaction  of  stones;  and  the  limits  of  the  mass, 
though  this  may  project  into  the  epigastrium,  will  scarcely  be 
those  of  a  gastric  cancer.  But  the  most  certain  safeguard  against 
error  is  careful  and  repeated  examination  of  the  urine. 

And  as  regards  the  urine,  the  observations  of  Rommelaere* 
seem  to  show  that  its  analysis  may  be  of  value  even  in  the  diag- 
nosis of  the  different  forms  of  gastric  disease.  Thus,  a  cancerous 
ulceration  of  the  stomach  is  attended  with  decrease  in  the  amount 
of  urea  and  of  the  chlorides  daily  excreted.  In  simple  gastric 
ulcer  these  are  in  normal  amount  or  in  excess  ;  so  is  the  urea. 


*  Journal  de  Medecine  de  Bruxelles,  1883  ;  quoted  iu  the  Lancet,  Sept.  1  and 
Oct.  27,  1883. 


526  MEDICAL   DIAGNOSIS. 

In  spreading  gastric  ulcer  the  chlorides  in  the  urine  are  decreased, 
but  there  is  normal  or  hyper-azoturia. 

Dilatation  of  the  Stomach. — This  happens  frequently  in 
connection  with  ohstruction  of  the  pylorus,  whether  cancerous  or 
fibroid,  but  it  is  also  met  with  independently  of  this  structural 
lesion.  The  latter  form  occurs  from  weakening  of  the  muscular 
coats  produced  by  malnutrition  or  impaired  innervation,  and  has 
been  noticed  as  an  attendant  upon  anaemia  or  hysteria,  or  following 
fevers,  or  obstruction  of  the  ujjper  part  of  the  bowel,  or  compres- 
sion of  the  pylorus  by  an  enormous  gall-stone,*  or,  as  Bamberger 
mentions,  dislocation  of  the  stomach  by  omental  hernias.  Edinger 
has  proved  that  it  may  be  associated  with  amyloid  degeneration 
of  the  vessels  or  of  the  muscular  coat  of  the  stomach.  The  chief 
signs  of  a  dilated  stomach  in  either  form  are  the  rejection  of  food, 
mostly  in  large  quantities  and  retained  for  days ;  fermented  and 
vomited  matter  containing  often  torulse  and  sarcinse ;  extension 
of  the  tympanitic  note  of  the  gastric  region,  detected  by  ])ercus- 
sion,  to  much  below  the  umbilicus ;  a  splashing  sound  when  the 
patient  moves,  particularly  after  drinking,  and  gurgling  on  sudden 
pressure ;  the  low  line  of  dulness  occasioned  by  fluids  in  the  dis- 
tended organ,  and  the  change  of  the  dulness  with  the  position 
of  the  patient ;  and  slowly-progressing  emaciation.  In  doubtful 
cases  the  organ  may  be  examined  and  its  limits  traced  by  distend- 
ing it  with  carbonic  acid,  generated  by  first  swallowing  bicarbo- 
nate of  sodium  and  then  tartaric  acid.  Displacement  of  the  right 
kidney  has  been  observed  in  a  number  of  cases. 

The  sormds  of  the  heart  heard  over  the  dilated  stomach  often 
have  a  metallic  ring,  but,  irrespective  of  this,  peculiar  gurgling 
sounds,  systolic  in  rhythm  and  evoked  by  the  action  of  the  heart, 
have  been  met  with  by  Franck  and  other  observers.  Dilatation 
of  the  stomach  may  occasion  nervous  symptoms ;  even  tetanus  has 
been  noticed. f  The  dilatation  occasionally  happens  in  an  acute 
manner,  and  occurs  in  children  |  as  well  as  in  adults.  As  a  rule, 
the  muscular  coat  is  not  hypertrophied,  but  in  the  cases  in  whicli 
an  obstruction  at  the  pylorus  exists,  this  is  frequent. 


*  Minkowski,  quoted  by  Ewakl. 

•f  Bulletins  et  Memoires  des  Hopitaux  de  Paris,  t.  xx.,  1884. 

X  Arch.  Gen.  de  Med.,  August,  1884. 


DISEASES   OF   THE    INTESTINES   AND    PERITONEUM.        527 

To  tell  the  atonic  cases  from  those  due  to  narrowing  at  the 
pylorus  is  generally  not  difficult :  we  can  detect  a  hard  swelling, 
or  find  the  resistance  with  a  stomach  sound.  In  cancerous  ob- 
struction the  gastric  juice  contains  no  hydrochloric  acid,  whereas 
excessive  acidity  from  free  hydrochloric  acid  is  the  rule  in  other 
forms  of  stomach  dilatation,  and  has  been  particularly  observed  in 
the  atonic  form.* 

Dilatation  of  the  stomach  may  be  confounded  with  dilatation 
of  the  large  intestine.  But  the  gastric  symptoms  of  the  former 
malady  are  of  great  significance.  Moreover,  we  may  make  use 
of  the  salol  test  in  the  discrimination.  Salol  is  not  acted  upon 
by  the  acid  gastric  juice,  but  is  changed  into  salicylic  acid  by  the 
alkaline  intestinal  secretion.  The  salicylic  acid  manifests  itself 
in  the  urine  of  healthy  persons  in  from  half  an  hour  to  an  hour, 
as  shown  by  the  addition  of  a  drop  of  the  tincture  of  chloride  of 
iron  to  the  urine  giving  it  a  deep  brownish-red  color.  In  dilata- 
tion of  the  stomach  salicylic  acid  does  not  appear  for  two  or 
three  hours  after  salol  has  been  taken. 


SECTION  II. 

DISEASES   OF   THE   INTESTINES   AND   OF   THE   PEEITONEUM. 

In  considering  the  diseases  of  the  intestines,  we  meet  with 
symptoms  the  import  of  which  we  have  examined  in  connection 
with  affections  of  the  stomach.  We  encounter  nausea,  vomiting, 
and  impaired  digestion.  These  disturbances  are  sympathetic  or 
dependent  upon  coexisting  gastric  disorder;  they  do  not  serve, 
therefore,  as  trustworthy  guides  in  intestinal  maladies.  The  signs 
upon  which  we  rely  more  implicitly  are  pain  and  the  feecal  dis- 
charges. As  regards  the  former,  we  draw  the  truest  inferences 
from  its  kind  rather  than  from  its  mere  occurrence.  The  study 
of  the  fsecal  discharges  tells  us  in  a  more  direct  manner  what  is 
going  on. 

Alvine  Discharges. — To  examine  briefly  their  appearances : 

*  Germain  See,  Bull,  de  I'Acad.  de  Med.,  May,  1888. 


528  MEDICAL   DIAGNOSIS. 

Watery  stools  are  observed  Avlienevcr  a  large  quantity  of  the 
serum  of  the  blood  finds  its  way  through  the  intestinal  eoats. 
They  are  met  Avith  after  the  administration  of  saline  purgatives, 
in  serous  diarrhoea,  and  in  cholera.  Their  hue  varies:  they  may 
be  almost  colorless,  or  tinged  with  yellow.  Sometimes,  although 
very  thin  and  watery,  they  are  decidedly  yellow  ;  again  they  are 
rendered  turbid  by  the  dissemination  of  whitish  flocculi  of  cast-off 
epithelium,  or  by  mucus.  Whether  they  be  yellow  or  colorless 
dei)ends  on  the  existence  or  non-existence  in  them  of  frecal  matter 
and  of  bile.  In  a  prognostic  point  of  view,  the  most  colorless 
evacuations  are  the  most  dangerous. 

The  presence  of  an  excessive  quantity  of  mucus  renders  the  dis- 
charges less  consistent  than  natural ;  yet,  unless  they  contain  more 
or  less  serum,  they  are  not  of  necessity  liquid.  The  appearance 
they  present  is  similar  to  that  of  the  white  of  an  egg;  or  the 
whitish  masses  of  mucus  surround  the  lumps  of  fseces,  or  are 
intermingled  with  the  fluid  alvine  discharges. 

Pus  in  large  amount  and  unmixed  with  faeces  is  discharged  only 
when  an  abscess  has  ruptured  into  some  part  of  the  intestine. 
Stools  composed  of  faeces  and  pus  are  encountered  in  chronic  in- 
flammation and  in  ulceration  of  the  bowels ;  and  whitish,  creamy 
streaks  indicate  the  presence  of  the  foreign  substance.  Yet  the 
pus  may  be  so  intimately  blended  Avith  the  faeces,  or  with  masses 
of  mucus,  as  to  require  the  microscope  for  its  detection. 

Stools  consisting  entirely  of  bile  are  rarely  met  with.  More 
generally  there  are  other  elements  joined  to  the  voided  secretion 
of  the  liver.  An  excess  of  bile  in  the  alvine  discharges  gives 
rise  to  evacuations  of  a  yellowish-broAvn  or  yellow  hue,  which 
darken  on  exposure  to  the  air.  When  the  alimentary  tube  is 
highly  acid,  the  resulting  color  is  green.  Both  these  kinds  of 
stools  are  commonly  called  "bilious;"  but  the  latter  is  less 
absolutely  so  than  the  former.  A  deficiency  of  bile  manifests 
itself  by  clayey,  sometimes  even  by  almost  white,  stools.  The 
normal  color  of  faeces  is  due  to  urobilin.  It  is  the  changed  bili- 
rubin fi'om  the  bile.    Bile-pigment  is  not  found  in  healthy  stools. 

Blade  stools  result  from  the  action  of  certain  medicines,  as  of 
iron;  from  a  vitiated  condition  of  the  bile  and  intestinal  secre- 
tions; or  from  the  effusion  of  blood  into  the  alimentary  canal. 
At  all  events,  when  the  hemorrhage  proceeds  from  the  stomach 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUJ\r.         029 

or  the  upper  part  of  tlie  canal,  tlie  stools  have  a  black,  tarry 
appearance;  when  from  tlie  lower  section  of  the  tuljo,  pure  hlood 
is  passed,  or,  if  it  be  small  in  quantity,  a  blood-streaked  mucus. 
Should  any  doubt  exist  as  to  whether  the  dark  discharges  be 
dependent  upon  the  presence  of  blood,  let  them  be  diluted  with 
water ;  they  will  assume  a  reddish  tinge  if  this  be  the  cause  of 
the  abnormal  color. 

The  odor  of  the  evacuations  is  extremely  offensive  in  fevers  of 
a  low  type,  and  when  the  intestinal  secretions  are  vitiated.  So, 
too,  at  times  in  smallpox  and  in  cholera.  Acidity  of  the  intes- 
tinal canal,  as  in  the  intestinal  catarrh  of  children  and  of  adults,* 
or  in  rheumatism  or  gout,  imparts  to  the  stools  a  sour  smell  and 
an  acid  reaction.     The  reaction  in  health  is  mostly  alkaline. 

In  cases  of  constipation  it  may  be  important  to  notice  the  shape 
of  the  passages,  because  this  may  show  whether  an  impediment  in 
the  gut  has  flattened  or  otherwise  altered  them.  In  fevers,  as 
well  as  in  affections  of  the  intestinal  mucous  membrane,  whether 
inflammatory  or  not,  we  often  derive  information  from  studying 
the  form  of  the  voided  matter.  Figured  stools  succeeding  to  fluid 
passages  are  always  of  favorable  omen.  We  also  note  whether 
the  stools  contain  masses  of  undigested  matter,  and  its  kind. 

Chemical  and  microscopical  examinations  of  the  faeces  are  not 
often  made;  yet  chemistry  and  the  microscope  may  be  frequently 
of  great  service.  They  e-nable  us,  for  instance,  to  recognize  with 
certainty  that  the  yellowish  lumps  contained  in  the  evacuation, 
or  the  greasy  film  which  collects  upon  its  surface,  consist  of  fat. 
The  microscope,  too,  detects  masses  of  muscular  fibre,  of  elastic 
tissue,  of  starch-corpuscles,  of  fat,  coagulated  albumen,  red  cor- 
puscles, leucocytes,  and  various  fungoid  growths,  micro-organisms, 
and  parasites.  It  exhibits,  in  the  fsecal  discharges  of  all  diseases 
in  which  the  stools  readily  decompose,  masses  of  crystals  of  the 
triple  phosphates ;  in  typhoid  fever,  shreds  of  slough  from  the 
enteric  ulcers,  and  bacilli ;  in  tubercular  ulceration  of  the  bowel, 
ifcubercle-bacilli.  The  main  normal  ingredient  of  fsecal  matter  is 
mucin.f     Peptone  occurs  only  in  disease.|     One  drawback  to  the 


*  Jaksch,  op.  cit.  f  Hoppe-Sevler,  Handbucli. 

J  Jaksch,  op.  cit.     See  also  on  this  and  other  points  Nothnagel's  researches, 
Beitrage  zur  Phj'siologie  und  Pathologie  des  Darms,  Berlin,  1884. 

34 


530  MEDICAL   DIAGXOSIS. 

use  of  chemical  research  for  clhiical  purposes  is  the  uncertain  com- 
position of  the  faeces,  owing  to  the  number  of  elements  derived 
from  the  food. 

The  study  of  the  alvine  discharges  is  of  service  not  merely  iu 
intestinal  complaints,  but  equally  in  the  many  maladies  in  which 
the  alimentary  tube  sympathizes  or  becomes  involved.  But  to 
return  to  the  uncomplicated  intestinal  diseases,  grouping  them  as 
they  may  be  recognized  by  pain  and  peculiarity  in  the  frecal  dis- 
charges, and  describing  with  them,  for  the  sake  of  convenience, 
the  affections  of  tlic  peritoneum. 


Diseases  attended  with  Paroxysms  of  Pain  referred  chiefly  to 
the  Middle  or  Lower  Part  of  the  Abdomen,  and  not  asso- 
ciated with  marked  Tenderness  or  with  Fever, 

The  type  of  these  is  colic. 

Colic. — This  is  an  intestinal  pain,  paroxysmal  in  its  charac- 
ter, and  usually  combined  with  constipation,  but  unattended  with 
febrile  symptoms.  The  pain  is  of  a  severe  griping,  or  pinching, 
or  twisting  kind,  and  is  commonly  referred  to  the  neighborhood 
of  the  umbilicus.  It  is  generally  relieved  by  jiressure.  Yet  this 
is  not  so  invariable  as  it  is  held  to  be  ;  for  sometimes  there  is  some 
soreness  with  the  pain,  and,  indeed,  a  sliglit  soreness  not  unfre- 
quently  remains  after  the  paroxysm  has  passed  off.  While  the 
pain  lasts,  the  countenance  wears  an  anxious,  frightened  expres- 
sion;  tlie  skin  is  cold,  or  covered  with  clammy  pcrs})i ration ;  the 
pulse  is  depressed.  Occasionally  there  is  vomiting,  and  in  severe 
cases  the  abdominal  walls  are  tense  or  raised  in  hard  knots  l>y  the 
spasmodic  contraction  of  tlie  muscles.  An  attack  may  last  only 
a  few  minutes,  or,  with  trifling  remissions,  for  several  hours. 

Some  persons  are  very  liable  to  attacks  of  colic.  Those  who 
suffer  from  indigestion,  or  are  enfeebled  by  exhausting  maladies, 
are  predisposed  to  them  ;  so  also  are  hysterical,  gouty,  and  rheu- 
matic individuals.  As  to  the  exciting  causes,  they  are  various ; 
and  somewhat  according  to  its  different  causes,  colic  presents  dif- 
ferent forms.     Let  us  indicate  the  more  prominent. 

Colic,  simple  and  unconnected  with  a  disease  of  the  bowel. — Now, 
in  these  cases,  which  are  generally  called  spasmodic  colic,  the  jmr- 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         531 

oxysmal  pain  may  have  a  diverse  origin.  It  may  Ije  the  result  oi' 
direct  excitation  of  the  peripheral  intestinal  nerves  by  the  presence 
of  irritating  substances  in  the  alimentary  canal,  such  as  indigest- 
ible food,  cold  or  acid  drinks,  hardened  faeces,  gases,  morbid  secre- 
tions, worms,  medicines,  or  poisons.  It  may  proceed  from  an 
irritation  of  the  central  nervous  system  reflected  to,  and  manifest- 
ing itself  in,  the  intestinal  nerves.  It  may  be  sympathetic,  and 
produced  by  a  morbid  state  of  the  adjacent  abdominal  viscera. 

1.  Colic  owing  to  food  difficult  of  digestion  is  very  common, 
especially  at  the  time  of  year  when  fruit  is  beginning  to  ripen. 
Sometimes  it  is  caused  by  food  taken  in  quantities  greater  than 
the  digestive  organs  can  assimilate.  Hence  it  is  frequent  in  chil- 
dren at  the  breast  who  are  overnourished,  and  in  persons  in  deli- 
cate health  with  enfeebled  digestive  powers.  The  form  of  colic 
under  discussion  is  often  attended  with  vomiting  and  diarrhoea ; 
it  may  be  of  only  a  few  hours'  duration,  or  it  may  last  for  several 
days. 

Colic  arising  from  distention  of  the  intestines  with  flatus,  or 
''  flatulent  colic,"  is  the  result  of  the  decomposition  of  food  in  the 
alimentary  canal ;  sometimes,  however,  the  gases  are  extricated 
from  morbid  secretions,  or  are  exhaled  directly  from  the  blood- 
vessels. The  abdomen  is  very  tympanitic  and  greatl}'  distended, 
and  the  flatus  is  from  time  to  time  discharged,  with  evident  relief 
to  the  patient.  Hysterical  persons  are  very  subject  to  this  form 
of  colic. 

Colic  from  accumulation  of  hardened  fseces  is  preceded  by  obsti- 
nate constipation,  and  is  usually  a  tedious  disorder.  The  accessions 
of  pain  are  easily  enough  remedied  by  emptying  the  bowels ;  but 
they  are  constantly  recurring. 

Colic  from  the  presence  of  morbid  secretions  in  the  intestinal 
canal  is  not  so  often  encountered  as  that  from  indigestible  food 
or  retained  faecal  masses.  Yet  it  is  occasionally  met  with  in 
cases  of  diarrhoea  attended  with  a  disordered  state  of  the  intestinal 
■  functions ;  even  in  the  so-termed  bilious  colic  the  intestinal  pain 
is  not  purely  sympathetic,  but  is  owing  to  the  irritating  character 
of  the  bile  discharged  into  the  intestine. 

This  "  bilious  colic"  is  often  preceded  by  nausea,  loss  of  appe- 
tite, and  a  coated  tongue.  The  paroxysms  of  pain  frequently  go 
hand  in  hand  with  vomiting, — first  of  the  contents  of  the  stomach, 


532  MEDICAL   DIAGNOSIS. 

tlicn  of  bile.  Thov  are  in  general  accompanied  or  soon  followed 
by  a  yellowish  tinge  of  the  conjunctiva^  by  tenderness  in  the 
region  of  the  liver,  and  by  a  desire  to  go  to  stool.  The  bowels 
are,  however,  ajjt  to  be  obstinately  constipated.  Bilious  colic  is 
common  in  malarious  districts ;  it  occurs  especially  during  the 
summer  and  autumnal  months,  and  frc(piently  follows  exjiosure. 
It  sometimes  begins  with  a  chill,  and,  unlike  the  other  forms  of 
colic,  it  has  as  companions  febrile  excitement,  and  a  full,  frequent 
pulse.     ]Malarial  colic  may  occur  in  an  epidemic  form.* 

2.  In  the  second  class  of  cases  to  which  allusion  has  been  made, 
colic  is  dependent  upon  some  abnormal  condition  affecting  pri- 
marily the  great  centres  of  innervation.  The  colic  arising  from 
fright,  from  anger ;  that  happening  in  nervous  females  and  hypo- 
chondriac males ;  perhaps  that  proceeding  from  sudden  exposure 
to  cold ;  the  form  which  is  sometimes  seeu  coexisting  Avith  neu- 
ralgic pains  in  other  parts  of  the.  body, — in  short,  all  those  cases 
which  are  spoken  of  as  nervous  colic,  might  here  be  mentioned. 
The  attack  is  sudden,  and  not  commonly  of  long  duration ;  but 
it  is  very  apt  to  be  repeated. 

The  so-termed  "  metallic  colics"  are  further  instances  of  colic 
produced  through  agents  which  act  primarily  on  the  general 
nervous  system.  This  is  at  any  rate  true  of  lead  colic.  Copper 
colic  exhibits  paroxysms  of  severe  pain  like  those  caused  by  the 
poisonous  influence  of  lead ;  but  it  is  attended  with  nausea,  vom- 
iting, diarrhoea,  tenesmus,  an  abdomen  distended  and  tender  to 
the  touch ;  in  other  words,  it  is  I'ather  an  inflammation  of  the 
intestine  with  colicky  pain,  than  uncomplicated  colic.  Lead  colic, 
on  the  other  hand,  is  a  pure  colic.  The  distinguishing  marks  of 
lead  colic  are  the  bluish-gray  line  along  the  gums ;  the  contracted 
abdomen ;  the  obstinate  constipation ;  the  great  relief  usually 
afforded  to  the  pain  by  pressure ;  the  duration  of  the  pain  ;  its 
marked  and  agonizing  exacerbations;  and  the  history  of  the  case. 
The  signs  of  the  lead  poisoning  also  manifest  themselves  in  other 
parts  of  the  body,  as  will  be  elsewhere  more  specially  considered. 

3.  Affections  of  various  organs  may  give  rise  to  colic,  by  sym- 
pathy, and  generally  through  the  intervention  of  tlie  nervous 
system,  to  which  the  irritation  is  first  transferred,  and  from  which 

*  American  .Journal  of  the  Medical  Sciences,  April,  1872. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         5.33 

it  is  then  reflected.  Thus,  colic  is  a  not  uncommon  attcindant  on 
morbid  states  of  the  kidneys,  liver,  bladder,  testicles,  uterus,  or 
ovaries,  and  on  disordered  menstruation.  Yet  we  must  not  forget 
that  the  pain,  although  spoken  of  as  colic,  is  often  not  strictly 
intestinal,  but  is  merely  a  pain  radiating  from  the  affected  organs 
themselves. 

Colic  arising  in  consequence  of  some  abnormal  state  of  the  bovjel. 
— In  the  preceding  illustrations  of  colic  the  disorder  was  viewed 
as  occurring  in  a  healthy  bowel.  But  colic  may  have  only  the 
significance  of  a  symptom,  and  be  combined  with  an  altered 
structure  or  a  changed  position  of  the  intestine.  We  meet,  indeed, 
with  colicky  pains,  undistinguishable  from  those  of  pure  colic, 
linked  to  an  organic  disease  of  the  bowel,  and  under  circumstances 
some  of  which  forbid  the  idea  of  a  spasm.  They  are  encountered 
in  dysentery;  enteritis;  hernia;  ulceration;  intussuscej)tion ;  stran- 
gulation ;  twisting ;  strictures ;  distention, — in  fact,  in  the  most 
various  morbid  states  of  the  intestine.  And  colic  as  a  symptom 
can  be  discriminated,  as  far  as  the  pain  is  concerned,  from  colic 
as  an  idiopathic  disorder,  only  by  a  careful  study  of  the  history 
and  the  concomitant  phenomena  of  the  case.  In  several  of  the 
maladies  cited,  however,  the  more  transitory  nature  of  the  pain, — 
or  gripings,  as  they  are  termed, — in  others,  the  presence  of  fever 
and  of  tenderness,  serve  as  guides  in  diagnosis.  Fever  and  sore- 
ness to  the  touch  are  also  met  with  in  that  form  of  inflammation 
of  the  bowel  which  happens  after  exposure  or  after  the  retroces- 
sion of  rheumatism  from  some  external  part,  and  which  is  com- 
monly known  as  rheumatic  or  inflammatory  colic. 

Having  thus  indicated  the  various  forms  of  colic,  and  having 
alluded  to  the  relation  they  bear  to  structural  diseases  of  the  in- 
testines and  to  affections  of  adjacent  viscera,  I  shall  only  here 
again  insist  on  the  necessity  of  tracing  out  in  every  case,  as  far  as 
possible,  the  cause  of  the  painful  malady,  so  as  to  know  if  any 
serious  mischief  lie  at  the  bottom  of  it ;  and  shall  but  add  a  few 
words  with  reference  to  the  disorders  with  which  uncomplicated 
colic,  or  that  which  is  held  to  be  purely  spasmodic,  may  be  con- 
founded.    They  are : 

Gastralgia  ; 

Perforation  of  the  Intestine; 

Strangulated  Hernia  ; 


534  medical  diagnosis. 

Passage  of  Gall-Stoxes; 

Nephralgia  ; 

Spasm  of  the  Bladder; 

Uterine  Colic; 

Neuralgia  of  the  Dorsal  and  Lumbar  Nerves; 

Abdominal  Aneurism  and  Tumors;  Diseases  of  the 
Spine  ; 

Enteritis  and  Peritonitis, 

Gastralgia. — In  gastralgia  the  pain  is  seated  in  the  epigastric 
region ;  whereas  in  colic,  or  enteralgia,  as  it  is  called  by  some,  the 
pain  is  either  in  the  neighborhood  of  the  umbilicus,  or  raj)idly 
shifts  its  position  from  that  point  to  different  j^arts  of  the  abdo- 
men, and  is  often  connected  with  a  spasmodic  contraction  of  the 
abdominal  muscles.  Again,  the  history  in  cases  of  gastralgia  ; 
the  fact  that  the  attacks  happen  most  frequently  after  meals ;  their 
association  with  signs  of  a  disordered  stomach, — indicate  the  organ 
in  which  the  pain  arises. 

And  much  the  same  general  signs,  in  addition  to  the  marked 
constipation  and  the  visible  movements,  enable  us  to  distinguish 
those  instances  of  peristaltic  disturbance  of  the  stomach  to  which 
Kussmaul  *  has  called  attention,  and  in  which  the  drawing  pain 
is  apt  to  be  referred  to  the  intestine ;  indeed,  the  peristaltic  dis- 
order may  spread  to  it. 

Perforation  of  the  Intestine. — When  paroxysms  of  pain  have 
their  origin  in  perforation  of  the  intestine,  the  extreme  prostra- 
tion and  collapse  show  that  they  are  not  produced  by  a  harm- 
less disorder  like  colic.  Further,  the  abdominal  distress  is  in 
such  cases  preceded  by  symptoms  of  a  diseased  state  of  the  stomach 
or  the  intestines ;  and  if  the  patient  live  sufficiently  long  after  the 
accident,  the  pain  is  followed  by  great  distention  of  the  abdomen 
and  extreme  tenderness, — in  fact,  by  the  signs  of  peritonitis. 
However,  the  difiPerential  diagnosis  is  occasionally  very  difficult. 
Esi^ecially  is  it  so  in  typhoid  fever ;  for  in  this  affection  colic  is 
readily  induced,  or  perforation  of  the  intestine  may  be  brought 
on  by  very  slight  exciting  causes ;  and,  moreover,  peritonitis,  so 
several  excellent  observers  think,  may  occur  without  perforation. 

Strangulated  Hernia. — All  mechanical  obstructions  of  the  in- 

*  Sammlung  Klinischer  Yortrage,  No.  181,  .June,  1880. 


DISEASES    OF   THE    INTESTINES    AND    PERITONEUM.        535 

testine  will  lead  to  paroxysms  of  intestinal  jjaiii.  They  arc  met 
with  in  cases  of  intussusception  and  of  ileus ;  they  are  equally 
frequent  in  cases  of  strangulated  hernia.  In  all,  the  obstinate 
constipation  must  arouse  suspicion  regarding  the  true  nature 
of  the  complaint.  To  detect  a  hernia  a  local  examination  is 
required ;  and  a  careful  search  at  the  usual  seats  of  this  affec- 
tion ought,  therefore,  to  be  made  in  every  instance  of  severe  or 
protracted  colic.  Persons  have  lost  their  lives  in  consequence 
of  the  neglect  of  this  simple  precaution  against  disastrous  error. 

Passage  of  Gall-stones. — The  passage  of  a  gall-stone  is  gener- 
ally attended  with  paroxysms  of  intense  pain  which  are  readily 
mistaken  for  colic.  There  is,  as  a  rule,  the  same  absence  of  fever 
and  of  tenderness.  Indeed,  pressure  is  often  resorted  to  in  order 
to  mitigate  the  suffering,  and  thus  the  resemblance  to  colic  is 
heightened.  The  points  of  distinction  from  colic  are,  the  position 
of  the  pain  in  the  epigastric  region  ;  its  sudden  beginning  and 
sudden  termination ;  the  severe  nausea  and  vomiting  attending 
the  attack  ;  the  jaundice ;  and  the  voiding  of  gall-stones  with  the 
stools.  The  latter  sign,  however,  though  a  positive  one,  assists 
less  in  the  discrimination  of  the  disorder  than  would  appear  at 
first  sight ;  partly  because  it  does  not  serve  as  a  means  of  indi- 
cating the  nature  of  the  affection  until  its  close,  partly  because 
the  stone  often  escapes  detection  in  the  fseces.*  The  other  circum- 
stances have,  therefore,  a  more  available  diagnostic  value.  Yet 
even  they  do  not  enable  us  to  distinguish  positively  between  the 
transit  of  a  biliary  concretion  from  the  gall-bladder  to  the  intes- 
tine, and  the  bilious  colic  which  is  joined  to  derangement  of  the 
function  of  the  liver.  The  repetition  of  the  attack  is  always  a 
strong  reason  for  suspecting  it  to  be  owing  to  a  discharge  of  calculi 
from  the  gall-bladder ;  and  so  are  severe  retching  and  vomiting, 
the  sudden  supervention  of  jaundice,  and  the  localized  epigastric 
pain.  But  these  phenomena,  too,  it  may  here  be  mentioned,  are 
produced  by  hepatio  neuralgia,  which  in  rare  cases  is  believed  to 
happen  independently  of  gall-stones.  And  there  is  nothing  by 
which  we  can  discriminate  this  malady — the  very  existence  of 


*  The  best  way  to  find  the  stone  is  to  pass  the  evacuation  through  a  sieve  :  this 
is  more  certain  than  covering  the  dischai'ge  with  water.  The  stone  may  not  come 
from  the  bowels  for  some  davs  after  the  attack  of  colic. 


536  MEDICAL    DIAGNOSIS. 

wli it'll  is,  indeed,  denied — exeept  its  recurrence  after  certain  inter- 
vals, the  alternations  with  other  affections  of  the  nervous  system, 
and  the  slightest  touching  of  the  part  inducing  at  times  the  acute 
pains.*  There  is  said  to  be  an  increase  of  temperature  over  the 
gall-bladder  during  an  attack  of  gall-stones. f 

Sometimes  gall-stones  are  closely  simulated  by  impacted  fseces, 
■which  occasion  colicky  pains,  and  even  jaundice,  by  pressure. 
The  pain  is  at  once  removed  by  morphia  given  hypoderniically, 
and  a  dose  of  oil  brings  away  the  hardened  faeces.  The  attacks 
may  recur,  and  are  always  relieved  in  the  same  manner.  The 
swelling  in  the  right  side  may  sometimes  be  readily  detected. 

Among  the  rarer  symptoms  attending  or  following  the  passage 
of  gall-stones,  temporary  dilatation  of  the  heart  and  tricuspid  re- 
gurgitation have  been  noticed,^;  just  as  temporary  mitral  insuffi- 
ciency has  been  observed  in  jaundice. 

Where  the  gall-stones  are  large  and  have  become  impacted  in 
their  course  toward  the  intestine,  they  give  rise  to  inflammation 
which  may  lead  to  ulceration  and  to  the  discharge  of  the  concre- 
tion— generally  then  very  large — into  the  intestine  or  stomach. 
Subsequently  an  obliteration  of  the  duct  may  happen  ;  or  the  in- 
flammation and  ulceration  of  the  duct  may  result  in  perforation 
into  the  peritoneum.  In  some  cases  the  gall-stones  are  voided 
through  the  abdominal  walls,  in  consequence  of  their  having 
caused  inflammation  of  the  gall-bladder  and  subsequent  adhe- 
sions to  the  abdominal  parietes.  The  fistulous  passages  discharge 
pus  and  bile,  and  occasionally  fresh  concretions :  they  may  last 
for  years ;  but  in  time  they  generally  heal.  As  regards  the  other 
forms  of  fistulous  communications  alluded  to,  they  very  rarely 
present  symptoms  so  peculiar  as  to  warrant  anything  like  a  cer- 
tain diagnosis.§ 

Nephrakjia. — Paroxysms  of  pain  with  intervals  of  comparative 
ease  and  unassociated  with  fever  occur  in  nephralgia,  or  pain  of 
the  kidney,  and  are,  therefore,  often  mistaken  for  colic.  Now, 
nephralgia  is  generally,  although  not  invariably,  caused  by  the 


*  See  the  cases  of  Budd,  on  Diseases  of  the  Liver ;  of  Andral,  Clinique  Medi- 
cale,  tome  ii.  ;  and  of  Frerichs,  Diseases  of  the  Liver. 

f  .Jules  Cyr,  Traite  sur  TAffection  calculeuse,  Paris,  1884. 

+  Potain,  quoted  by  See,  Maladies  du  Coeur,  Paris,  1883. 

§  See  a  collection  of  cases  by  Murchison,  Edinb.  Med.  Journ.,  July,  1857. 


DISEASES   OF   THE    INTESTINES    AND    PERITONEUM.         /337 

passage  of  a  calculus  tlirough  the  ureter.  Its  symptoms,  besides 
the  paiu,  are  numbness  of  tlie  thigh,  nausea  and  vomiting,  a  con- 
stant desire  to  make  water,  and  aching  and  drawing  up  of  the 
testicle.  The  patient,  as  in  colic,  is  restless,  and  seeks  relief  by 
frequently  changing  his  position.  The  pain  comes  on  suddenly, 
and  is  excruciating.  It  is  felt  in  the  loins,  usually  on  one  side, 
and  shoots  along  the  track  of  the  ureter  to  the  corresponding  hip 
and  thigh.  It  sometimes  extends  to  the  pelvis  or  toward  the 
umbilicus,  and  is  often  attended  with  tenderness  in  the  course  of 
the  ureter.  Occasionally  it  is  almost  exclusively  felt  at  the  hip. 
When  the  stone  reaches  the  bladder,  the  pain  ceases  as  abruptly 
as  it  began;  though  sometimes  there  is  still  discomfort  produced 
by  the  stone  interfering  with  the  act  of  micturition.  During  the 
attack  the  urine  is  passed  in  small  quantities  at  a  time.  It  is 
high-colored  ;  sometimes  it  contains  a  little  blood.  If  it  be  col- 
lected, and,  after  all  pain  has  disappeared,  be  carefully  examined, 
a  small,  hard  body  or  a  sandy  deposit  is  generally  detected,  and 
reveals  the  cause  of  the  past  anguish.  It  is  from  the  presence  of 
the  sandy  deposit  that  the  complaint  has  received  popularly  the 
name  of  a  fit  of  "  the  gravel." 

From  the  description  given,  it  will  be  seen  that  in  several 
respects  the  disorder  is  like  intestinal  colic.  The  seat  of  the  pain 
is  a  point  of  distinction ;  yet  in  neither  complaint  is  the  seat  en- 
tirely characteristic.  It  is  not  always  strictly  umbilical  in  colic  ; 
it  is  not  always  exactly  in  the  region  of  the  ureter  or  kidney 
in  nephralgia.  Of  more  importance  is  the  state  of  the  urinary 
functions,  which  are  comparatively  undisturbed  in  colic.  Again, 
the  numbness  of  the  thigh  and  the  retraction  of  the  testicle  are 
valuable  diagnostic  marks ;  they  would  be  absolutely  decisive, 
were  they  constantly  present  in  nephralgia. 

Spasm  of  the  Bladder. — The  bladder  is  sometimes  the  site  of 
paroxysms  of  violent  pain,  supposed  to  attend  upon  a  spasm  of 
the  viscus.  There  is  an  intense  desire  to  urinate,  which  the  pass- 
ing of  water  does  not  allay.  The  pain  is  not  steady  ;  it  is  accompa- 
nied by  a  sense  of  constriction  at  or  near  the  pelvis,  and  sometimes 
by  tenesmus,  and  may  extend  to  the  kidneys,  to  the  thighs,  and  to 
the  sacrum  ;  or  the  irritation  may  be  communicated  to  the  penis, 
and  cause  erections.  If  the  sphincters  be  involved,  the  urine  can- 
not be  voided.     The  bladder  distends  ;  there  is  intense  anxiety, 


538  MEDICAL    DIAGNOSIS. 

with  restlessness;  the  })iilse  is  feeble;  the  skin  is  cold, and  covered 
with  clammy  perspiration. 

A  spaSm  of  the  bladder  may  be  caused  by  the  presence  of  a  stone 
or  of  irritating  urine.  It  is  also  encountered  in  gout  and  hysteria, 
and  as  the  result  of  stimulating  diuretics.  Violent  fright,  too,  may 
occasion  it.  It  sometimes  proceeds  from  a  disorder  of  adjacent 
structures,  such  as  of  the  rectum,  or  of  the  uterus.  Now  and  then, 
as  Sir  Benjamin  Brodie  pointed  out,  it  is  associated  with  inflam- 
mation or  suppuration  of  the  kidney,  and  the  vesical  pain  is  so 
intense  that  it  withdraws  attention  from  the  organ  most  affected. 
To  distinguish  it  from  colic  is  not  difficult ;  the  position  of  the 
pain  and  the  disturbed  condition  of  the  urinary  functions  serve  as 
guides.  It  resembles  more  closely  nephralgia  ;  as  in  nephralgia, 
too,  after  the  fit  is  relieved,  the  important  indication  is  to  prevent 
its  repetition  by  endeavoring  to  remove  its  source. 

Uterine  Colic. — The  painful  sensations  experienced  by  some 
women  at  their  menstrual  periods  may  come  on  in  paroxysms 
similar  to  those  of  colic.  In  truth,  the  pain  is  often  spoken  of 
as  uterine  colic,  and  at  times  continues  for  many  days,  persisting 
during  the  whole  menstrual  period,  or  even  longer.  In  some  of 
these  cases  the  complaint  is  localized  in  the  uterus ;  in  others, 
more  especially  in  the  ovaries,  which  are  then  tender  to  the  touch. 
Similar  attacks  of  pain,  also  accompanied  by  congestion  or  even 
by  inflammation  of  the  ovaries,  are  occasionally  met  with  as  the 
result  of  falls  or  of  blows  on  the  hypogastric  region. 

Now,  with  reference  to  the  disorder  first  alluded  to,  or  ordinary 
dysmenorrhoea,  it  may  be  generally  easily  discriminated  from  colic 
by  its  occurrence  with  the  setting  in  of  the  menstrual  flow  ;  by 
the  pain  remitting  rather  than  intermitting ;  by  the  seat  of  the 
pain  in  the  pelvis,  or  the  lower  part  of  the  abdomen  ;  by  its  not 
uncommon  association  with  sickness,  nausea,  and  vomiting  ;  and 
by  the  fact  that  all  the  signs  of  disordered  menstruation  have 
happened  over  and  over  again  at  the  menstrual  periods. 

AVhere  the  ovaries  are  very  much  congested  or  inflamed,  whether 
or  not  the  affection  exist  in  connection  with  dysmenorrhoea,  or 
occur  in  consequence  of  other  causes,  among  which  gonorrhoea 
may  be  one,  the  pain,  tenderness,  and  swelling  in  the  hypogastric 
region ;  the  not  unusual  numbness  and  flexed  position  of  one  or 
both  thighs ;  the  febrile  irritation,  and  the  hysterical  symptoms  ; 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         039 

the  retention  of  the  urine ;  the  violence  of  the  paroxysms  of  pain, 
and  the  duration  of  the  mahidy, — form  a  group  of  phenomena 
very  dissimilar  to  those  of  ordinary  cases  of  colic. 

Ovarian  neuralgia  has  symptoms  like  those  of  ovaritis,  but  is 
without  fever,  and  the  pain  is  apt  to  alternate  with  neuralgia 
elsewhere.     It  rarely  occurs  in  both  ovaries  at  once.* 

Neuralgia  of  the  Dorsal  and  Lumbar  Nerves ;  Abdominal  Neu- 
ralgia.— The  dorsal  and  lumbar  nerves  are  subject  to  neuralgic 
affections,  which  exhibit,  like  colic,  paroxysms  of  pain  unac- 
companied by  fever.  But  Valleix  has  taught  us  to  look  for 
spots  painful  to  the  touch  in  the  course  of  the  aching  nerves,  and 
has  shown  that  the  disturbance  of  the  nerves  supplying  the  ab- 
dominal parietes  manifests  itself  on  one  side  of  the  body  only, 
whereas  an  irritation  of  the  intestinal  nerves  obeys  no  such  law. 

In  neuralgia  of  the  lumbar  nerves,  or  lumho- abdominal  neural- 
gia, the  pain  is  commonly  felt  in  the  hypogastric  region,  a  little 
to  one  side  of  the  median  line.  In  this  situation,  too,  there  is 
localized  soreness  on  pressure ;  the  other  tender  spots  are,  gener- 
ally, one  a  little  to  the  outside  of  the  first  or  second  lumbar  ver- 
tebra, and  one  immediately  above  the  middle  of  the  crest  of  the 
ilium.  In  women,  who  are  by  far  the  greatest  sufferers  from  the 
disease,  there  is  sometimes  also  a  painful  place  about  the  middle 
of  the  Fallopian  tube,  or  on  the  neck  of  the  uterus ;  in  men,  a 
point  on  the  scrotum  here  and  there  is  found  sore  to  the  touch. 
These  spots  of  tenderness  serve  as  characteristic  signs ;  and  they 
enable  us  to  separate  neuralgia  not  only  from  colic,  but  also  from 
lumbago,  and  from  rheumatism  of  the  abdominal  walls. 

Besides  these  forms  of  neuralgia,  we  find  other  kinds  of  ab- 
dominal neuralgia,  which  may  be  mistaken  for  colic.  They  are 
attacks  of  pain  affecting  especially  the  mesenteric  plexus  or  the 
solar  plexus,  happening  in  paroxysms  of  great  severity,  and  at- 
tended with  a  sense  of  faintness  and  annihilation.  The  disorder 
is  unconnected  with  lead  poisoning  or  any  of  the  causes  which 
produce  colic,  is  often  excited  by  exertion,  and  is  associated  with 
debility  and  relieved  by  an  antineuralgic  treatment.  In  some 
cases  it  is  clearly  of  malarial  origin ;  and  in  every  case  we  must 
lay  great  stress  on  the  frequent  recurrence  of  the  pain  and  on  the 

*  Clifford  Allbutt,  Liverpool  and  Munchester  Med.  Eep.,  1873. 


540  MEDICAL    DIAGNOSIS. 

history  to  enable  us  to  discriminate  between  the  neuralgic  com- 
plaint and  colic.  The  distinctitai  from  gastraljiia  can  be  made 
only  by  the  more  marked  gastric  symptoms,  and  the  absence  of  or 
the  less  decided  prostration  and  sense  of  fainting  in  this  malady.* 

Abdominal  Aueurii<iii  and  Tumors  ;  Diseases  of  the  Spine. — In 
all  of  these  we  may  find  violent  pain  of  a  paroxysmal  kind  re- 
ferred to  various  portions  of  the  abdomen,  and  unaccompanied 
by  fever,  ^^'e  judge  that  the  pain  is  not  colic,  by  its  frequent 
repetition ;  by  its  Avant  of  association  ^ith  intestinal  or  gastric 
disturbance ;  by  its  being,  although  liable  to  exacerbations,  so 
steadily  present  at  some  part  either  of  the  spine  or  of  the  abdo- 
men ;  and  by  the  attending  symptoms  and  signs  occasioned  by  an 
abdominal  tumor,  or  by  a  disease  of  the  lower  dorsal  or  of  the 
lumbar  vertebrae. 

Entcrit'iH  and  Peritonitis. — Inflammations  of  the  intestines  and 
of  the  peritoneum  also  give  rise  to  severe  abdominal  pain.  But 
it  is  more  constant,  and  is  linked  to  great  tenderness,  and,  in  acute 
cases,  to  symptoms  of  high  febrile  excitement.  Thus  enteritis  and 
peritonitis  belong  to  a  different  group  of  diseases, — a  group  of  in- 
flammatory affections,  which  I  shall  describe  somewhat  at  length, 
before  contrasting  the  symptoms  of  inflammation  of  the  intestines 
or  of  the  peritoneum  Avith  those  of  colic. 

Diseases  attended  with  Pain  and  marked  Tenderness  in  the 
Umbilical  Eegion  or  diflPased  over  the  Abdomen. 

Acute  Enteritis. — Enteritis  means,  by  common  consent,  in- 
flammation of  the  small  intestine,  especially  of  the  portion  that 
lies  between  the  duodenum  and  the  colon.  The  morbid  process 
may  extend  to  the  colon ;  if,  however,  it  involves  a  large  portion 
of  the  latter,  it  is  colitis  or  dA'sentery.  There  are  two  forms  of 
enteritis  :  one  in  which  the  mucous  membrane  of  the  boAvel  is 
alone  affected  ;  muco-enteritis  or  intestinal  catarrh.  In  the  second, 
more  than  the  mucous  tunic  is  implicated  ;  there  is  also  inflam- 
mation of  the  submucous  and  muscular  coats,   or  even  of  the 

*  A  number  of  cases  of  abdominal  neuralgia  are  reported  by  Handfield 
Jones,  in  his  Treatise  on  Functional  Nervous  Disorders ;  and  bj^  Porcher, 
in  Amer.  Journ.  of  Med.  Sci.,  July,  1809. 


DISEASES   OF   THE    INTESTINES    AND    PERITONEUM.        o41 

serous  investment  of  the  bowel.  To  this  variety  of  the  complaint 
the  term  enteritis  is  by  several  writers  restricted ;  and  it  is  to  this 
form  of  the  malady,  occurring  acutely,  that  the  description  about 
to  be  given  more  particularly  applies. 

The  symptoms  of  an  acute  attack  of  enteritis  are  those  of  colic, 
attended  with  fever  and  tenderness.  The  disorder  may  begin 
with  the  symptoms  of  colic,  and  in  such  cases  the  inflammation 
of  the  bowel  is  said  to  have  supervened  on  colic  ;  or  it  may  set  in 
with  a  chill  and  fever,  and  extreme  thirst.  When  the  disease  is 
fully  established,  the  fever  runs  high  ;  the  pulse,  tense  and  full  at 
the  onset,  becomes  small  and  Mary,  although  it  remains  frequent. 
There  are  nausea  and  vomiting,  and  sometimes  most  distressing 
fits  of  retching,  produced  either  by  sympathy,  or  because  the 
stomach  shares  in  the  inflammation.  The  tongue  is  clean,  or  it 
is  covered  with  a  white  coat,  or,  again,  it  may  be  red  and  dry. 
The  bowels  are  constipated  ;  sometimes  there  is  diarrhoea,  or  con- 
stipation alternating  with  diarrhoea.  The  stools  may  contain  a 
small,  quantity  of  blood,  but  they  very  rarely  contain  pus.  The 
appetite  is  lost,  the  thirst  great.  The  pain,  as  in  colic,  is  parox- 
ysmal. It  begins  near  the  umbilicus,  and  thence  may  shift  to 
various  parts  of  the  abdomen,  but  not  to  the  epigastrium ;  yet  it 
is  not  so  violent  nor  does  it  cease  so  entirely  as  in  colic,  but  rather 
exacerbates,  and  then  changes  to  a  dull  feeling  of  distress.  It  is 
greatly  increased  by  pressure,  and  the  patient  seeks  relief,  as  in 
peritonitis,  by  lying  on  his  back  with  his  thighs  flexed,  so  as  to 
relax  the  abdominal  muscles.  Toward 'the  right  of  the  umbilicus 
it  is  not  uncommon  to  find  a  marked  pulsation,  as  if  from  throb- 
bing of  the  abdominal  aorta  or  of  its  large  branches, — a  sign  to 
which  Stokes*  directed  attention.  This  pulsation  may  be  very 
annoying.  In  looking  over  the  notes  of  my  cases  on  which  the 
description  of  the  symptoms  of  enteritis  just  given  is  based,  I 
find  one  in  which  neither  the  thirst,  nor  the  pain,  nor  the  nausea 
and  vomiting  occasioned  as  much  distress  as  the  violent  throbbing 
in  the  abdomen. 

In  those  instances  of  the  malady  which  advance  to  a  fatal  ter- 
mination, the  pulse  becomes  quick  and  irregular  and  loses  its  tense- 
ness ;  hiccough  appears ;  the  abdomen  swells ;  the  features  are  hag- 

*  Article  "  Enteritis,"  in  Cyclopaedia  of  Practical  Medicine. 


542  MEDICAL   DIAGNOSIS. 

gard,  and  expressive  of  great  suifering  ;  and  the  patient's  strength 
becomes  gradually  exhausted.  The  worst  and  most  hopeless  cases 
of  the  disease  are  those  dependent  on  mechanical  obstruction  of 
the  bowel,  whether  it  proceed  from  organized  bands  in  which  a 
loop  of  intestine  is  caught,  or  from  invagination,  or  from  accumu- 
lation of  hardened  fieces,  or  from  a  hernial  strangulation. 

Among  the  symptoms  of  enteritis  mentioned,  the  i)ain  is  one 
of  the  most  important  for  diagnosis.  It  is  never  absent,  save  in 
rare  instances  in  which  the  inflammation  is  very  intense  at  the 
onset.*  Still  more  important  is  the  great  tenderness.  This  en- 
ables us  to  say  that  the  case,  in  spite  of  the  colicky  pains,  is  not 
colic.  It  warns  us  not  to,  resort  to  remedies  merely  to  relieve 
the  seemingly  spasmodic  pain.  It  tells  us,  when  it  succeeds  to 
ordinary  colic,  that  inflammation  of  the  bowel  has  supervened. 
It  admonishes  us  not  to  administer  strong  cathartics  to  over- 
come the  constipation  which  appears  in  consequence  of  the  severe 
inflammation. 

The  disease  in  its  violent  form  just  described  bears  a  close  re- 
semblance to  peritonitis :  Ave  shall  presently  see  what  are  its  dis- 
tinguishing marks.  But  there  is,  as  above  stated,  another  variety 
of  the  disease,  a  mild  variety,  or  muco-cnteritis,  in  which  the  dis- 
turbance is  limited  to  the  mucous  membrane.  The  main  features 
of  this  intestinal  catarrh  are  the  same,  but  they  stand  out  in  less 
bold  relief.  There  are  griping  pains,  a  slight  soreness  to  the  touch, 
general  uneasiness,  loss  of  appetite,  thirst,  nausea,  and  sometimes 
vomitino;.  But  we  find  onlv  slio;ht  fever  :  and  the  febrile  excite- 
ment  remits  in  the  morning.  Diarrhoea  is  present,  and  the  stools 
are  sometimes  very  offensive.  This  form  of  the  disease  may  ter- 
minate, as  the  severer  inflammation  generally  does,  in  less  than 
a  week  ;  yet  it  may  persist  for  several  weeks,  and  thus  gradually 
lapse  into  a  chronic  complaint.  It  is  common  in  children,  espe- 
cially during  dentition.  It  is  also  observed  when  irritating  food 
or  secretions  occupy  the  alimentary  canal  for  any  length  of  time, 
or  after  exposure  to  cold  and  damp,  particularly  when  the  skin  is 
perspiring  freely,  and  as  an  attendant  upon  the  exanthemata.  It 
resembles  typhoid  fever.  Indeed,  it  is  sometimes  difficult,  espe- 
cially in  children,  or  in  the  intestinal  catarrh  of  catarrhal  fever, 

*  Andral,  Pathologie  interne,  tome  i.  p.  47. 


DISEASES   OF   THE   INTESTINES   AND    PERITONEUM.        543 

to  know  whether  we  are  dealing  with  a  ease  of  simple  intestinal 
catarrh,  or  with  the  intestinal  symptoms  of  enteric  fever.  The 
state  of  the  cerebral  functions,  the  pain  and  gurgling  in  the  iliac 
fossa,  and  the  high  temperature,  may  clear  up  the  doubt ;  yet  in 
some  cases  nothing  but  the  eruption  and  the  course  of  the  symp- 
toms will  do  so. 

The  symptoms  just  described  belong  to  catarrh  of  the  ileum,  or 
of  the  ileum  and  the  ascending  colon.  Tn  catarrhal  inflammation 
of  the  duodenum  there  is  often  constipation  in  place  of  diarrhoea. 
Pain  between  two  and  three  hours  after  the  taking  of  food,  loss 
of  appetite,  coated  tongue,  fetid  breath,  marked  digestive  disorder, 
flatulency,  and  jaundice  are  prominent  among  the  symptoms.  The 
pain  is  apt  to  come  on  in  paroxysms  like  gastralgia,  although  re- 
ferred somewhat  lower  than  the  stomach ;  these  seizures  last  several 
hours,  and  slowly  subside.  We  frequently  find  a  certain  amount 
of  soreness  developed  by  deep  pressure  in  the  right  hypochondrium 
and  the  upper  part  of  the  umbilical  region.  There  is  weakness, 
with  much  despondency,  and  slight  elevation  of  temperature.  An 
acute  attack  lasts  two  or  three  weeks.  In  the  chronic  form  the 
duration  may  be  as  many  months. 

Another  affection  which  is  liable  to  be  mistaken  both  for  en- 
teritis and  for  typhoid  fever  has  been  described  by  Klob.*  The 
chief  symptoms  are  violent  pains  in  the  hypogastric  region,  with 
vomiting,  thready,  frequent  pulse,  high  temperature,  and  the  rapid 
supervention  of  somnolence  and  coma.  In  some  instances  hemor- 
rhages happen.  Hemorrhagic  erosions  are  found  in  the  stomach, 
and  bloody  infiltrations  in  the  jejunum;  the  parenchyma  of  the 
mesenteric  glands,  their  lymphatics,  and  the  thoracic  duct  are  in- 
filtrated with  blood  ;  the  spleen  is  enlarged.  The  disorder  shows 
then  a  striking  hemorrhagic  tendency,  and  is  supposed  to  be  a 
blood-affection  similar  to  pseudoleuksemia. 

Acute  Peritonitis. — As  in  acute  enteritis,  so  in  acute  peri- 
tonitis, pain  and  tenderness  are  the  most  significant  symptoms. 
To  these  are  joined  fever,  distention  of  the  abdomen,  and,  fre- 
quently, cold  sweats,  nausea,  vomiting,  and  obstinate  constipation. 
The  disease  begins  with  chilly  sensations  or  protracted  rigor.  To 
these  succeed  fever,  and  abdominal  pain  and  distention.      The 

*  Wien.  Med.  Zeitung,  quoted  in  Lond.  Med.  Eecord,  Feb.  1875. 


544  MEDICAL   DIAGNOSIS. 

fever  runs  high  at  the  onset ;  it  exhibits  a  dry,  burning  slcin,  an 
axillary  temperature  of  103°  and  upwards,  a  pulse  frequent,  but, 
as  in  acute  inflammations  of  the  mucous  and  serous  membranes 
below  the  diaphragm,  small  and  wiry.  However,  both  the  char- 
acter of  the  ]>ulse  and  that  of  the  skin  change  as  the  malady 
progresses.  The  pulse  will  be  less  tense  and  more  developed  as 
the  inflammation  subsides,  or  feeble  and  flickering  if  the  disor- 
der proceed  to\\ard  a  fatal  termination.  The  skin  is  frequently 
covered  with  cold  sweats.  The  temperature  is  irregular,  and  may 
sink  below  the  normal.  The  features  are  sharpened  and  wear 
the  look  of  death,  even  in  cases  which  ultimately  recover. 

The  pain  is  constant  and  severe.  It  may  exacerbate,  but  it 
never  intermits.  At  first  the  pain  is  confined  to  a  particular 
point ;  but  as  tlie  inflammation  extends,  so  it  extends  over  the 
\vhole  abdomen.  It  is  increased  by  the  slightest  pressure,  be  that 
pressure  exerted  by  the  hand  or  by  movements  of  any  kind.  To 
obviate  the  pressure,  the  patient  lies  on  his  back  with  his  thighs 
flexed,  and,  however  tired  of  retaining  the  same  position,  he  does 
not  change  it.  The  descent  of  the  diaphragm  augments  the  pain : 
instinctively,  therefore,  he  refrains  from  drawing  long  breaths,  and 
his  respiration  is  short  and  frequent  and  purely  thoracic. 

The  abdominal  distention  is  in  part  owing  to  meteorism,  in  part 
to  the  liquid  effused  into  the  peritoneum.  Percussion  tells  us  in 
individual  cases  how  far  each  factor  acts  as  a  cause  of  the  enlarge- 
ment, by  the  tympanitic  or  the  dull  sound  elicited.  Palpation, 
too,  reveals  the  presence  of  liquid.  Yet  percussion  or  palpation 
ought  to  be  employed  only  with  the  greatest  care,  on  account  of 
the  pain  they  occasion.  The  fluid  does  not  gravitate  as  invariably 
as  in  ascites  to  the  lower  portion  of  the  belly.  It  is  often  caught 
in  sacs  formed  by  the  membrane  adhering  in  spots ;  and  thus 
circumscribed  dulncss  may  be  found  at  one  or  several  parts  of  the 
abdomen.  Sometimes  the  roughening  of  the  membrane  gives  rise 
to  a  distinct  friction  sound. 

Independently  of  the  abdominal  pain  and  swelling,  we  meet,  in 
acute  peritonitis,  with  constipation,  nausea  and  vomiting,  licadache, 
a  suppression  of  the  urinary  discharge,  and  in  rare  instances  with 
priapism  ;  of  these  symptoms,  constipation  is  the  most  constant. 
The  liowcls  are  never  relaxed,  except  in  the  puerperal  form  of  the 
malady.     The  constipation  is  caused  by  the  paralyzed  state  of  the 


DISEASES   OF   THE    INTESTINES    AND    PERITONEUM.         545 

intestine,  to  portions  of  which  the  inflammation  may  spread ;  or 
by  the  lymph  ghiing  together  the  coils  of  the  bowels. 

Death  in  acute  peritonitis  is  commonly  preceded  by  enormous 
tumefaction  of  the  belly,  cold  sweats,  a  pinched  countenance,  and 
a  rapid,  flickering  pulse.  When  recovery  takes  place — unfortu- 
nately a  rarer  issue  of  the  malady  than  its  fatal  termination — it  is 
commonly  very  slow  and  gradual :  the  symptoms  diminish  one 
by  one ;  they  do  not  cease  suddenly ;  and  often  morbid  conditions 
remain  which  prolong  greatly  the  patient's  illness  and  may  lead 
in  themselves  to  a  disastrous  result.  It  is,  therefore,  impossible 
to  foretell  the  duration  either  of  the  acute  disease  or  of  its  con- 
sequences. Andral  fixes  the  average  length  of  an  acute  attack  at 
between  six  and  nine  days,  and  of  a  subacute  attack  at  from 
twenty  to  thirty  days.  But  the  nature  of  the  malady  is  such  that 
many  cases  last  a  longer,  many  a  much  shorter  period. 

The  presence  of  gas  in  the  peritoneal  cavity,  as  Flint  insists 
upon,*  is  a  valuable  sign  of  perforative  peritonitis.  Tympanitic 
resonance  over  the  hepatic  region  is  thus  occasioned.  On  the  other 
hand,  when  the  hepatic  dulness  is  found,  the  inference  is  a  fair  one 
against  perforation  of  stomach  or  intestine  as  a  cause  of  a  peri- 
tonitis that  is  detected. 

Acute  peritonitis  arises  only  very  occasionally  from  exposure 
to  cold  and  wet;  much  oftener  in  consequence  of  injuries  to  the 
abdomen,  such  as  blows,  stabs,  or  kicks ;  or  from  perforation  or 
laceration  of  some  of  the  abdominal  organs  and  discharge  of  their 
contents  into  the  peritoneal  cavity.  Uterine  injections  passing 
into  the  peritoneal  cavity  may  cause  peritonitis.  It  also  results 
from  rheumatism,f  or  from  a  poisoned  state  of  the  blood,  as,  for 
example,  the  peritonitis  of  childbed  fever.  It  sometimes  origi- 
nates from  an  inflammation  of  the  abdominal  viscera,  especially 
of  the  spleen,  intestines,  or  uterus  and  its  appendages,  spreading 
to  their  serous  covering,  and  thence  extending  more  or  less  rap- 
idly. Again,  other  morbid  states  of  the  abdominal  organs,  such 
as  cysts  of  the  ovaries,  intestinal  intussusception,  or  strangulated 
hernia,  may  compress  or  irritate  the  membrane,  and  lead  to  in- 
flammatory action.     Owing  to  these  diverse  sources,  peritonitis 


*  Medical  News,  Phila.,  Feb.  11,  1882. 
t  Schmidt's  Jahrbiicher,  No.  9,  1873. 
35 


546  MEDICAL   DIAGNOSIS. 

presents  varieties  which  exhibit  points  of  difference  sufficient  to 
require  special  notice. 

The  inflammation  produced  by  extravasatio)i  into  the  peritoneal 
sac  is  characterized  by  its  sudden  development.  The  matters  ex- 
travasated  may  be  blood,  or  bile,  or  urine,  or  the  contents  of  the 
stomach.  Most  frequently  perforation  of  the  stomach  or  intestine 
lies  at  the  bottom  of  the  mischief.  Whatever  its  cause,  the  per- 
foration is  inmiediately  followed  by  collapse;  and  tenderness  and 
distention  of  the  abdomen  soon  make  their  appearance.  Yet 
peritonitis  may  set  in  rapidly  in  cases  in  which  there  has  been  no 
rupture ;  and,  on  the  other  hand,  in  rare,  very  rare,  instances,  the 
contents  of  the  alimentary  canal  may  be  discharged  into  the  sac 
without  giving  rise  to  inflammation.* 

The  peritonitis  of  childbed  fever,  or  puerperal  peritonitis,  is 
principally  distinguished  by  its  occurring  dnring  the  puerperal 
state.  Its  symptoms  are,  so  far  as  the  peritoneal  inflammation 
is  concerned,  those  of  any  other  kind  of  peritonitis,  except  that 
diarrhoea,  instead  of  constipation,  is  often  present.  The  tempera- 
ture rises  speedily  to  a  considerable  height,  to  104°  or  105°,  and 
continues  high  with  irregular  remissions.  The  uterus  or  the 
uterine  appendages  are  generally  first  attacked ;  and  it  is  in  these 
regions  that  pain  and  tenderness  are  first  felt.  The  inflammation 
spreads  to  their  serous  investment,  or  it  may  be  primarily  seated 
in  that  investment :  in  either  case  it  soon  involves  the  entire  mem- 
brane. But,  independently  of  the  symptoms  of  the  local  disorder, 
there  are  phenomena  which  clearly  belong  to  the  diseased  state  of 
which  the  inflammation  of  the  peritoneum  is  but  a  local  expres- 
sion ;  there  are  evidences  of  a  poisoned  state  of  the  blood  and  of 
a  general  disturbance  of  the  system.  We  find  delirium,  black 
vomit,  exudation  into  the  pericardium  and  pleura,  features  of 
disease  not  met  with  in  the  purely  local  malady. 

What  the  poison  is  which  determines  the  terrible  disease,  we 
cannot  here  inquire.  It  may  be,  as  some  think,  atmospheric ;  it 
may  be,  as  is  much  more  generally  held,  septic,  from  the  absorp- 
tion of  putrid  matter  from  the  uterus ;  it  may  be  an  animal  virus 


*  Cases  reported  bj"^  Bardeleben  and  Siebert,  quoted  in  Henoch's  Clinic  of 
Abdominal  Diseases.  Instances  of  rapid  peritonitis  without  perforation  are 
given  by  Thirial,  L'Union  Medicale,  1853. 


DISEASES    OP   THE    INTESTINES    AND    PERITONEUM.         547 

transmitted  by  the  hand  of  the  attendant ;  the  complaint  may  be, 
as  many  believe,  closely  analogous  to  erysipelatous  inflammation ; 
it  may  be  eminently  contagious ;  it  may  not  be  so  at  all.  These 
are  not  points,  however  important  their  solution  to  the  well-being 
of  thousands  of  lying-in  women,  which  concern  us  here.  For 
diagnostic  purposes,  it  is  of  more  consequence  to  know  that  the 
malady  occurs  sporadically,  or  prevails  epidemically  and  endemi- 
cally  ;  that  its  features  change  ;  in  short,  that  while  childbed  fever, 
whatever  its  cause,  occasions  peritonitis,  peritonitis  does  not  con- 
stitute childbed  fever. 

Partial  or  local  peritonitis  is  almost  invariably  owing  to  a  pre- 
existino;  morbid  condition  of  some  abdominal  viscus.  Sometimes 
the  circumscribed  inflammation  is  protective  rather  than  calculated 
to  work  mischief.  It  arrests  a  destructive  perforation  of  the  mem- 
brane, or  it  limits  the  matter  discharged  to  a  certain  spot ;  it  may 
at  least  do  so  for  a  time,  for  general  peritonitis  is  very  apt  ulti- 
mately to  follow. 

Partial  peritonitis  often  pursues  a  subacute  rather  than  an  acute 
course.  It  may  end  in  adhesions  or  lapse  into  a  chronic  state.  Its 
symptoms  are  much  the  same  as  those  of  a  more  general  inflam- 
mation,— the  same  fever  and  constipation,  the  same  pain  and  ten- 
derness. The  fever  does  not,  however,  run  so  high,  and  the  pain 
and  the  great  tenderness  are  much  more  localized.  The  abdomen, 
also,  is  not  so  swollen  or  so  tympanitic.  But  perhaps  even  more 
frequently  than  in  general  peritonitis  are  found  accurately-limited 
spots  of  dulness  on  percussion  corresponding  to  circumscribed  col- 
lections of  pus  in  the  peritoneal  cavity. 

Partial  peritonitis  is  more  liable  than  the  general  disease  to  be 
confounded  with  other  disorders.  Yet  error  can  hardly  arise,  or, 
should  it  arise,  it  is  not  of  much  consequence,  provided  we  bear 
in  mind  that  it  is  precisely  with  the  morbid  states  of  the  viscera 
which  lie  below  the  peritoneum  that  the  circumscribed  inflamma- 
tion of  the  serous  membrane  is  usually  connected,  and  that  local 
peritonitis,  therefore,  frequently  attends  the  very  disorders  from 
which  it  is  sought  to  be  distinguished.  Let  us,  however,  examine 
into  some  of  the  complaints  with  which  peritonitis,  whether  local 
or  general,  may  be  confounded.  They  are— leaving  for  considera- 
tion elsewhere  typhlitis  and  perityphlitis — 

Acute  Gastritis  : 


548  medical  diagnosis. 

Acute  Enteritis  ; 

Acute  Pancreatitis  ; 

Metritis  ; 

Cystitis  and  Distention  of  the  Bladder; 

Rheumatism  of  the  Abdominal  Walls; 

Abdominal  Hysteria  ; 

Colic. 

Acute  Gusiriiis.  —  Acute  inflammation  of  the  stomach  can 
scarcely  be  mistaken  for  inflammation  of  the  peritoneum,  pro- 
vided attention  be  paid  to  the  history  of  the  case  and  to  the  seat 
of  the  pain.  The  former  disorder  begins  with  vomiting,  and  this 
continues  a  prominent  symptom  throughout ;  whereas  vomiting 
is  not  so  constant,  nor  does  it  occur  so  early,  in  peritonitis.  The 
pain  and  tenderness  are  limited  to  the  region  of  the  stomach  in 
gastritis  ;  they  are  diffused  and  accompanied  by  general  abdominal 
enlargement  in  peritonitis.  They  may,  it  is  true,  be  localized  when 
the  peritonitis  is  partial.  But  acute  inflammation  of  the  gastric 
peritoneum  is  hardly  encountered,  save  as  an  attendant  on  severe 
inflammation  of  the  stomach,  or  on  a  destruction  of  its  coats. 
And  in  the  first  instance  it  is  practically  gastritis  we  are  dealing 
with  ;  in  the  second,  the  history  of  the  case,  the  sudden  increase 
of  the  pain  and  tenderness,  and  the  development  of  fever  will  go 
far  toward  evincing  the  nature  of  the  affection.  However,  if 
a  partial  peritonitis  occurring  in  consequence  of  serious  gastric 
disease  be  subacute  or  chronic,  it  eludes  discovery. 

Acute  Enteritis. — Enteritis  differs  from  general  peritonitis  by 
the  less  extended  tenderness ;  by  the  seat  of  the  pain  near  the  um- 
bilicus, and  its  more  paroxysmal  character ;  by  the  comparative 
absence  of  tympanites  and  abdominal  tumefaction ;  and  by  the 
greater  prominence  of  nausea  and  vomiting.  It  is,  moreover,  a 
disease  far  less  violent  and  dangerous  than  acute  peritonitis ;  yet 
it  cannot  be  distinguished  with  certainty  from  the  partial  form 
of  this  disorder,  to  which,  in  truth,  some  of  its  symptoms  are 
clearly  owing. 

Acute  Pancreatitis. — This  is  a  cause  of  peritonitis  which  may 
be  easily  overlooked.  The  pancreatic  inflammation  mostly  arises 
in  consequence  of  the  extension  of  a  gastro-duodenal  inflamma- 
tion along  the  pancreatic  duct ;  or  it  may  follow  hemorrhage  into 
the  pancreas.     In  the  former  case  we  find  sudden  pain,  deep- 


DISEASES   OF   THE   INTESTINES   AND    PERITONEUM.        549 

seated,  constant,  or  paroxysmal,  tenderness,  and  tympany  in  the 
epigastrium  in  the  region  of  the  pancreas,  with  nausea  and  vomit- 
ing. This  is  gradually  followed  by  peritonitis  at  the  same  place, 
and  by  a  low  fever.  Constipation  is  frequent,  and,  with  the  other 
symptoms,  has  led  to  the  belief  of  acute  intestinal  obstruction 
and  to  laparotomy.  In  hemorrhagic  pancreatitis  the  symptoms 
run  a  rapid  course.  It  usually  proves  fatal  in  from  two  to  four 
days  ;  the  temperature  may  remain  normal.*  The  hemorrhage 
may  lead  to  gangrene.  In  either  case  the  signs  of  peritonitis  are 
marked.     Hemorrhage  may  occasion  sudden  death. f 

Metritis. — Inflammation  of  the  womb  is  not  likely  to  be  mis- 
taken for  general  peritonitis ;  the  pain  on  pressure,  which  they 
have  in  common,  is  confined  in  the  former  disease  to  the  uterus 
and  its  annexes,  and  there  is  little  or  no  tymj^anites.  It  is  thus 
only  that  the  acute  metritis  of  childbed  fever  may  be  distin- 
guished from  the  acute  general  peritonitis  of  the  same  malady. 
For  otherwise  the  resemblance  is  strong  :  in  both,  the  disease  is 
ushered  in  by  chills,  and  the  lochial  discharge  soon  diminishes  or 
ceases.  When  the  puerperal  malady  attacks  the  uterus  as  well  as 
the  whole  peritoneal  surface,  the  signs  of  inflammation  of  the 
serous  membrane  mask  those  of  inflammation  of  the  womb. 

A  local  inflammation  of  the  peritoneum  occurs  still  more 
constantly  as  an  attendant  on  inflammation  of  the  womb  and  its 
appendages,  whether  the  disorder  of  the  sexual  organs  be  or  be 
not  puerperal.  It  frequently  leads  to  collections  of  pus,  which  can 
be  readily  felt  through  the  parietes  of  the  abdomen  or  through 
the  rectum  and  the  vagina,  and  which  sometimes  discharge  into 
the  bowel  or  vagina  after  a  lingering  sickness.  The  proofs  that 
the  uterus  is  involved  in  these  cases  of  partial  peritonitis,  are  the 
signs  of  its  disordered  functions  and  the  excessive  pain  occasioned 
by  pressing  on  the  cervix  during  an  examination  per  vaginam. 

Cystitis  and  Distention  of  the  Bladder. — Both  inflammation  and 
distention  of  the  bladder  are  occasionally  mistaken  for  general 
acute  peritonitis.  An  acute  inflammation  of  the  bladder  gives 
rise  to  frequent  calls  to  pass  urine  :  yet  the  act  is  performed  with 
great  difficulty,  and  in  severe  cases  may  become  impossible ;  the 


*  Fitz,  Middleton-Golclsmith  Lecture  for  1889. 
f  Draper,  Transact.  Assoc.  Amer.  Phys.,  1886. 


550  MEDICAL   DIAGNOSIS. 

bladder  distends;  a  sense  of  uneasiness  is  felt  in  the  perineum; 
the  region  above  the  pubes  becomes  tender,  and  sounds  dull  on 
percussion  ;  the  unhai)py  suiferer  is  restless  and  distressed  ;  he  has 
the  excited  pulse  and  the  hot  skin  of  fever ;  at  times  vomiting 
and  hiccough  supervene;  and  death  is  preceded  by  gradually- 
deepening  coma.  Such  cases  resemble  those  of  peritonitis  with 
suppression  of  the  urinary  discharge  and  with  strangury.  But 
the  urine  voided  in  peritonitis  is  simply  high-colored,  like  that 
of  any  febrile  state.  In  cystitis  it  contains  large  quantities  of 
mucus  and  pus,  and  often  blood  and  crystals  of  phosphates. 
Again,  the  abdominal  tenderness  is  localized,  and  is  frequently 
accompanied  by  a  smarting  in  the  course  of  the  urethra.  Neither 
of  these  signs  is  encountered  in  peritoneal  inflammation,  and,  as  a 
rule,  the  temperature  in  this  is  higher.  The  disturbance  of  the 
urinary  organs  which  not  unfrequently  takes  place  in  the  latter 
disorder  is  attributed  to  inflammation  of  the  part  of  the  perito- 
neum covering  the  bladder  or  its  immediate  neighborhood. 

An  overdistentiou  of  the  bladder,  not  the  result  of  inflamma- 
tion of  its  coats,  may  produce  a  local  tenderness  spread  over  a 
considerable  portion  of  the  lower  part  of  the  abdomen.  But  the 
outline  of  the  dulness,  which  is  coextensive  with  that  of  the  ten- 
derness, the  fact  that  the  patient  has  generally  not  passed  urine 
in  any  quantity  for  a  considerable  time,  the  almost  normal  tem- 
perature, and  the  sudden  cessation  of  the  supposed  peritonitis  on 
passing  a  catheter,  show  the  true  nature  of  the  malady.* 

Inflammation  and  Abscess  in  the  Abdominal  Muscles. — When 
the  abdominal  walls  become  inflamed,  symptoms  are  occasioned 
which  are  not  always  easily  distinguished  from  those  of  acute 
peritonitis.  The  disease  is  attended  Avith  some  fever,  with  pain 
increased  by  movement,  by  the  act  of  coughing,  and  by  press- 
ure, and  sometimes  with  excessive  tenderness.  The  scat  of  the 
inflammation  is  generally  the  rectus  muscle  and  the  surround- 
ing cellular  tissue.  The  parts  on  one  side  of  the  umbilicus  are 
most  commonly  attacked,  and  it  is  there  that  a  hard  swelling  is 
perceived,  over  which  the  skin  is  rather  hot  and  sometimes 
red.     The  tumefaction  gradually  disappears  by  resolution,  or  else 

*  A  case  of  this  kind,  occurring  after  delivery,  is  given  by  Lever,  Guy"s 
Hospital  Reports,  2d  Series,  vol.  viii.  p.  41. 


DISEASES   OF    THE    INTESTINES    AND    PERITONEUM.        551 

fluctuation  becomes  from  day  to  day  more  distinct,  sliowing  that 
suppuration  is  taking  place;  and  tlie  pus  being  discharged,  imme- 
diate relief  follows,  and  the  pain  and  febrile  symptoms  instantly 
cease. 

Now,  the  disease  rarely  runs  a  very  acute  course ;  it  lasts  at 
least  a  week  or  two,  and  often  much  longer.  Where  much  of  the 
muscle  is  involved,  the  complaint  simulates  peritonitis, — more, 
however,  the  partial  than  the  general  kind.  Where  the  inflam- 
mation of  the  muscle  is  not  extended,  the  resemblance  to  inflam- 
matory affections  'of  the  organs  lying  underneath  the  point  of 
tenderness  is  even  greater  than  to  inflammation  of  the  peritoneum. 
Hepatitis,  splenitis,  and  gastritis  have  been  mistaken  for  the 
affection  of  the  abdominal  parietes.  These  errors  can  only  be 
avoided  by  taking  into  account  the  absence  of  disturbed  function 
of  the  suspected  viscus  ;  often,  too,  the  peculiar  swelling  furnishes 
a  clue  to  the  real  nature  of  the  case.  But  as  regards  signs  of 
disturbed  function,  we  must  bear  in  mind  that  these  are  produced 
occasionally  in  adjoining  viscera  by  mere  sympathy.  Thus,  we 
have  jaundice  in  abscesses  seated  in  the  walls  in  the  right  hypo- 
chonclrium.* 

Can  we  distinguish,  with  anything  like  certainty,  between  ab- 
scesses in  the  abdominal  walls  and  instances  of  partial  peritonitis 
leading  to  collections  of  pus  in  the  peritoneal  cavity  f  I  believe, 
not ;  for  in  both  there  is  a  tumefaction ;  in  both  the  general 
symptoms  are  much  the  same;  and,  as  happens  sometimes  in 
peritoneal  abscesses,  the  pus  presses  its  way  through  the  parietes 
of  the  abdomen.  How,  then,  are  we  to  know  where  was  the  seat 
of  its  formation  ?  W^henever  we  find  a  swelling  which  has  come 
on  gradually,  or  has  followed  a  blow  or  a  kick  on  the  abdomen, 
or  a  swelling  which  is  very  hard  before  fluctuation  appears; 
whenever  the  softening  of  the  tumor  is  immediately  preceded  by 
distinct  chills,  and  the  skin  covering  it  is  tense,  and  heated,  or 
reddish ;  wherever  there  is  nothing  pointing  to  the  occurrence 
of  partial  peritonitis,  as  an  attendant  on  visceral  disease,  or  as 
a  consequence  of  an  attack  of  general  peritonitis, — we  may  infer, 
from  the  history  and  the  signs,  that  the  affection  lies  in  the  ab- 
dominal walls.     But  the  skin  is  not  always  discolored  or  hot,  and 

*  As  mentioned  by  Habershon,  Diseases  of  the  Abdomen,  1878. 


552  MEDICAL   DIAGNOSIS. 

the  begiunino;  of  the  swellhig  is  sometimes  veiled  in  obscurity. 
In.  some  instances  I  have  seen,  in  which  there  was  great  doubt, 
the  aspirator  drew  off  a  very  oifensive  pus  and  broken-down 
material ;  and  I  looked  upon  this — as  the  sequence  proved,  cor- 
rectly— as  indicating  abscess  in  the  abdominal  walls.  Abscesses 
within  the  abdomen  seated  at  the  upper  part,  if  not  caused  by 
abscess  of  the  liver,  are,  as  Bristowe  accurately  points  out,*  largely 
due  to  perforation  of  one  of  the  hollow  viscera  with  circumscribed 
peritoneal  suppuration. 

But  it  is  not  every  case  of  abscess  in  the  walls  which  is  attended 
M'ith  symptoms  that  render  it  likely  to  be  mistaken  for  the  results 
of  inflammation.  Sometimes  the  preceding  tumefaction  is  so 
hard,  or  it  is  so  long  before  the  process  of  suppuration  sets  in,  that 
the  affection  is  more  liable  to  be  confounded  with  abdominal 
tumors.  The  most  trustworthy  points  of  difference  are  furnished 
by  a  study  of  the  history  of  the  case,  and  of  the  mode  of  inva- 
sion ;  by  the  slow  growth  of  the  tumor  on  the  one  hand,  and  its 
far  more  rapid  growth  on  the  other ;  and  by  the  absence,  or  at 
all  events  the  comparative  absence,  of  signs  denoting  serious  dis- 
turbance in  one  or  several  of  the  abdominal  viscera.  Then,  in 
doubtful  cases,  the  aspirator  or  the  exploring  needle  will  be  of 
use.  The  fluid  thus  obtained  shows,  under  the  microscope,  shreds 
of  broken-down  muscle  and  of  areolar  tissue,  mixed,  if  suppu- 
ration have  commenced,  with  pus.  Again,  stress  may  be  laid  on 
the  occurrence  of  chills  preceding  the  softening  of  the  mass.  In 
some  patients  the  inflammation  is  unaccompanied  by  any  appre- 
ciable signs ;  it  leads  to  gradual  changes  in  the  muscular  fibres, 
which  do  not  reveal  themselves  until  the  disorganized  muscle 
gives  way.  The  fibres  undergo  softening  or  a  true  fatty  meta- 
morphosis, and  the  slightest  force  suffices  to  produce  a  rupture. 
Not  a  few  cases  have  been  reported  in  which  one  of  the  recti  mus- 
cles has  been  torn  asunder  during  a  fit  of  coughing.  The  seat  of 
laceration  is  generally  about  midway  between  the  umbilicus  and 
the  pubes,  a  little  to  one  side  of  the  median  line ;  the  rent  fills 
with  blood,  occasioning  a  circumscribed  swelling  and  rigidity  of 
the  abdomen.  There  is  sometimes  pain,  with  nausea,  vomiting, 
and  obstinate  constipation.     Nay,  the  symptoms  have  mimicked 

*  Lancet,  Sept.  1883. 


DISEASES   OF   THE   INTESTINES   AND   PERITONEUM.        553 

SO  closely  a  strangulated  ventral   hernia  as  to  have  led  to  the 
performance  of  an  operation.* 

Rheumatism  of  the  Abdominal  Walk. — Occasionally  rheumatism 
attacks  the  abdominal  muscles,  and  gives  rise  to  local  symjDtoms 
similar  to  those  of  peritonitis.  But  the  pain  is  not  so  constant, 
nor  is  it  spontaneous,  as  in  this  disorder.  It  is  also  less  affected 
by  movements  or  by  pressure.  Not  that  these  diminish  it ;  on 
the  contrary,  they  aggravate  it.  But  deep  pressure  causes  little 
or  no  more  pain  than  slight  pressure  ;  and  it  is  only  during  certain 
motions — when  the  muscles  are  placed  on  the  stretch — that  the 
pain  is  severe,  or  sometimes,  indeed,  at  all  produced. 

The  pain  is  often  one-sided,  or,  at  any  rate,  much  more  marked 
on  one  side,  and  we  find  no  meteorism,  and  but  slightly  elevated 
temperature,  and  not  the  anxious  countenance  of  peritonitis.  More- 
over, the  attack  is  apt  to  happen  in  those  of  rheumatic  tendencies, 
and  there  is  concentrated,  highly-acid,  scalding  urine.  So  strong 
a  degree  of  similarity  may,  however,  exist  between  the  two  diseases 
as  to  keep  judgment  in  suspense.  In  such  cases  it  is  better  to 
treat  the  disorder  as  if  it  were  inflammation  of  the  peritoneum. 
In  point  of  fact,  it  may  happen  that  such  inflammation  does  suc- 
ceed to  the  rheumatic  affection  of  the  abdominal  muscles,  and  this 
occurs  chiefly  when  the  disturbance  in  the  muscles  forms  part  of 
an  attack  of  acute  rheumatism  having  a  decided  tendency  to  shift 
its  seat. 

Abdominal  Hysteria. — No  disease  simulates  peritonitis  more 
closely  than  hysteria.  The  abdomen  may  be  extremely  painful 
to  the  touch,  swollen  and  distended  with  gas,  fever  may  set  in 
temporarily,  and  yet  the  whole  disorder  be  purely  hysterical.  To 
illustrate : 

An  unmarried  woman,  twenty  years  of  age,  placed  herself  under 
my  care,  on  account  of  extreme  tenderness  of  the  abdomen  and 


*  Richardson's  case,  American  Journal  of  the  Medical  Sciences,  Jan.  1857. 
Further  instances  of  this  accident  are  given  by  Virchow,  in  the  Wiirzburg. 
Verhandl.,  Band  vii.  The  description  of  abscesses  in  the  abdominal  parietes 
I  have  drawn  from  cases  coming  under  my  own  notice,  from  manuscript  notes 
taken  by  Dr.  J.  K.  Kane  at  the  Philadelphia  Hospital,  and  from  the  cases 
collected  in  the  Dictionnaire  des  Dictionnaires  de  Medecine,  art.  "Abdomen." 
See  also  Paul  Deriencourt,  These  de  Paris,  1886,  No.  153 ;  Marsigny,  Arch. 
Med.  Beiges,  Bruxelles,  1886,  3e  ser.,  xxix. 


554  MEDICAL   DIAGNOSIS. 

febrile  irritation,  both  of  which  had  become  devck^pcd  in  a 
few  days.  The  abdomen  was  swollen  and  tympanitic,  and  so 
sensitive  that  it  would  not  bear  the  pressure  of  her  clothes ;  the 
pulse  was  frequent ;  the  skin  dry  and  warm  ;  the  tongue  slightly 
coated ;  the  bowels  constipated  ;  the  countenance  expressive  of 
distress.  Here  was  certainly  a  group  of  symptoms  like  those  of 
acute  peritonitis.  But  the  absence  of  the  wiry  pulse,  the  compar- 
atively slight  fever, — slighter,  certainly,  than  was  to  be  expected 
from  such  general  and  great  tenderness, — and  the  expression  of 
countenance,  arrested  my  attention.  I  found  that  the  patient  had 
had  similar  attacks  previously ;  that  they  had  come  on  sometimes 
shortly  before,  sometimes  shortly  after,  her  menstrual  period ;  but 
that  for  several  months  her  menses  had  ceased  to  flow.  The  ab- 
dominal tenderness  was  in  reality,  as  she  represented  it  to  be,  very 
great ;  yet  strong  pressure  produced  no  more  pain  than  the  lightest 
touch.  Nor  Avas  the  pain  increased  by  deep  inspiration,  or  by 
coughing,  or  by  extending  the  thighs.  Taking  all  these  circum- 
stances into  account,  as  well  as  her  age  and  sex,  and  her  nervous 
temperament,  instead  of  treating  her  for  acute  peritonitis,  cold- 
water  injections,  mild  purgatives,  and  a  mixture  of  assafetida  and 
valerian  were  employed.  Under  these  remedies,  all  the  symp- 
toms of  the  apparent  peritonitis  speedily  vanished. 

Yet  all  cases  of  abdominal  hysteria  do  not  pass  oif  so  quickly ; 
sometimes  they  are  much  more  persistent.  Then,  however,  they 
are  from  the  onset  unattended  with  fever,  or,  as  the  thermometer 
shows,  the  fever  soon  ceases.  The  absence  of  febrile  excitement, 
too,  especially  if  taken  in  connection  with  the  several  localized  and 
more  or  less  distinctly  circumscribed  spots  of  tenderness,  enables 
us  to  distinguish  between  peritonitis  and  those  instances  of  neural- 
gia of  nerves  supplying  the  abdominal  parietes,  to  which  women 
who  are  laboring  under  disorders  of  the  uterus  are  so  liable.  It 
is  in  these  cases,  as  w^ell  as  in  all  instances  of  abdominal  hysteria, 
that  the  thermometer  proves  a  most  useful  aid  in  the  diagnosis. 

Colic. — As  already  stated,  the  pain  of  colic  is  paroxysmal,  and 
not  attended  wnth  fever,  or  with  much,  if  any,  tenderness ;  while 
the  pain  of  an  inflamed  peritoneum  is  constant,  and  associated 
with  the  greatest  tenderness  and  Avith  fever.  Cases  of  colic  do 
indeed  occur  in  which  we  find  fever  and  some  tenderness ;  but 
these  signs  then  are  still  out  of   proportion  to  the  amount  of 


DISEASES   OF   THE   INTESTINES   AND    PERITONEUM.        555 

pain.  The  pulse  is  not  wiry,  nor  the  tenderness  so  exquisite  or 
so  diffused.  Further,  it  is  not  at  all  unlikely  that  in  such  cases 
the  peritoneum  is  really  in  parts  injected  or  slightly  inflamed 
We  know  that  even  a  more  severe  form  of  peritonitis  may  follow 
colic ;  why  should  not  an  injection  of  the  membrane  frequentl}* 
coexist  ? 

The  same  remarks  are  applicable  to  those  severe  paroxysmal 
pains  which  accompany  the  passage  of  gall-stones  or  of  urinary 
concretions,  or  which  occur  at  the  menstrual  periods.  They  are 
frequently  spoken  of  as  varieties  of  colic,  and,  as  far  as  their 
discrimination  from  peritonitis  goes,  there  is  no  difference, — it  rests 
on  the  same  grounds  precisely ;  for  when  there  is  fever  or  tender- 
ness on  pressure,  it  is  likely  that  inflammation  has  been  set  up  in 
those  parts  in  which,  or  in  the  neighborhood  of  which,  the  pain  is 
felt.  In  the  so-called  uterine  colic,  an  injection  of  the  peritoneum 
has  positively  been  demonstrated. 

Chronic  Peritonitis. — An  acute  attack  of  peritonitis  may 
imperceptibly  assume  a  chronic  form.  The  fever  gradually  dis- 
appears, or  at  all  events  lessens ;  but  the  exudations  into  the  peri- 
toneal cavity,  whether  organized  or  not,  remain,  and  so  do  some 
abdominal  pain  and  tenderness.  In  this  condition  the  patient 
may  continue  for  many  months,  now  and  then  a  fresh  inflamma- 
tion starting  up  in  the  peritoneum  and  giving  rise  to  acute  symp- 
toms, or  an  intercurrent  severe  diarrhoea  leading  to  rapid  loss  of 
strength.  Again,  the  disease  may  develop  slowly,  be  latent  from 
the  onset,  and  may  not  attract  attention  until  the  abdomen  swells. 
In  all  cases,  no  matter  what  their  origin,  if  they  last  for  any 
length  of  time,  debility  and  emaciation  become  marked  symptoms ; 
then  hectic  fever  is  observed ;  decided  effusion  into  the  peritoneum 
is  generally  noticed;  the  legs  become  oedematous;  and  the  patient 
may  die  worn  out  and  presenting  the  symptoms  of  pysemic  poison- 
ing. Where  recovery  takes  place,  the  exudation  into  the  peri- 
toneal cavity  is  either  discharged  through  adjacent  viscera;  or 
maybe  gradually  reabsorbed;  or  may  be  transformed,  more  or  less 
quickly,  into  tissue.  When  the  disease  terminates  in  this  way,  it 
is  apt  to  leave  its  traces  in  a  chronic  thickening  and  roughening 
of  the  peritoneum. 

Chronic  peritonitis  is  most  likely  to  be  confounded  with  affec- 
tions of  the  liver  which  are  attended  by  impediment  in  the  portal 


556  MEDICAL   DIAGNOSIS. 

circle ;  and  what  adds  to  the  difficulty  in  diagnosis  is,  that  the 
liver  is  apt  to  atrophy  in  chronic  diffuse  peritoneal  inflammation. 
The  most  trustworthy  signs  of  distinction  are  that,  in  the  latter 
aifection,  tenderness  exists,  and  is  under  any  circumstances  much 
greater  and  more  diffuse;  that  there  are  evening  exacerbations 
of  temperature,  a  quickened  i)ulse,  dark  stools ;  and  that,  if  the 
veins  of  the  abdomen  are  dilated,  their  dilatation  is  slight  and 
uniform. 

Chronic  peritonitis  more  usually  comes  on  and  ends  in  a  par- 
ticular fashion.  It  is  insidious  in  its  approach,  and  its  fatal  ter- 
mination is  preceded  by  evident  signs  of  tubercular  or  cancerous 
deposits  in  the  abdominal  cavity  or  in  the  lungs.  The  disease  is 
not  then  simply  chronic  peritonitis,  but  chronic  peritonitis  in  con- 
nection with  a  cachexia.  Cases  of  the  kind  are  commonly  of  long 
duration.  They  are  attended  with  ascites,  and  often  with  very 
considerable  abdominal  distention.  I  shall,  therefore,  postpone 
most  of  what  I  have  to  say  about  their  diagnosis  until  I  come  to 
abdominal  enlargements,  and  shall  then  consider  what  differences 
there  are  between  these  various  forms  of  chronic  peritoneal  affec- 
tions and  other  disorders  leading  to  ascites  and  to  consequent 
abdominal  distention. 

Diseases  attended  with  Pain  and  Tenderness  in  the  Eight 
Iliac  Fossa, 

Affections  of  the  Caecum  and  its  Appendix. — Standing 
clinically  in  close  connection  with  inflammatory  affections  of  the 
peritoneum,  are  the  disorders  of  the  caecum  and  its  appendix. 
They  frequently  give  rise  to  a  partial  peritoneal  inflammation; 
they  sometimes  lead  to  fatal  general  peritonitis.  Their  chief 
manifestations  are  localized  pain  and  tenderness,  and  a  tumefac- 
tion in  the  right  iliac  fossa.  In  truth,  they  are  the  disorders 
which  pre-eminently  occasion  signs  of  disturbance  in  this  region. 

Inflammation  is  the  most  common  of  the  morbid  processes 
affecting  the  caecum  and  its  appendix.  This  inflammation  may  be 
limited  to  the  caecum ;  it  may  have  its  seat  entirely  in  the  appen- 
dix. It  may  be  equally  violent  in  both  ;  it  may  cause  ulceration 
in  one  and  not  in  the  other.  It  may  originate  in  the  loose  areolar 
tissue  around  the  caecum ;  it  may  begin  in  the  caecum  and  spread 


DISEASES   OF   THE   INTESTINES   AND   PERITONEUM.        557 

from  its  peritoneal  covering  to  the  areolar  tissue  of  the  iliac  fossa. 
Here  are  certainly  conditions  which  are  different,  and  between 
which  it  would  be  very  desirable  to  be  able  to  discriminate.  But 
such  discrimination  is,  for  the  most  part,  impossible.  The  history 
and  progress  of  the  disease  may  determine  the  exact  diagnosis ; 
but  we  cannot  always  rely  upon  their  aid. 

Inflammation  of  the  csecum  or  of  its  appendix  is,  in  the  major- 
ity of  instances,  caused  by  accumulation  of  hardened  fteces,  or  by 
hardened  bodies  which  have  there  become  impacted,  such  as  dif- 
ferent kinds  of  seeds.  The  appendix  is  the  part  pre-eminently 
affected,  and  perforation  is  a  frequent  result.  Perforating  appen- 
dicitis is  most  often  seen  among  healthy  young  men,  and  the 
symptoms  may  have  been  latent  until  the  perforation  happens. 
Again,  successive  attacks  of  appendicitis  developing  a  chronic 
thickening  and  enlargement  of  the  parts  are  not  unusual.  Some- 
times the  csecal  disease  sets  in  suddenly  with  the  signs  of  a  severe 
local  peritonitis  in  the  right  iliac  fossa  ;  and  the  body  is  turned 
to  the  right  side  to  relax  the  muscles  of  that  side.  The  pain  and 
tenderness  soon  spread,  as  the  peritoneal  inflammation  becomes 
more  general.  But  usually  the  complaint  is  of  more  gradual  for- 
mation, and  presents  the  following  history  and  symptoms.  The 
patient  has  been  suffering  for  some  time  from  constipation,  or 
alternately  from  diarrhoea  and  constipation.  He  has  a  dull  pain 
referred  principally  to  the  iliac  fossa,  and  radiating  to  the  hips. 
When  the  iliac  region  is  examined,  it  is  tender  to  the  touch,  full 
and  hard,  and  sounds  dull  on  percussion,  while  around  the  dulness 
there  is  a  very  tympanitic  sound,  if  the  intestine,  as  it  often  is,  be 
much  distended  with  gas.  Colicky  pains  occur  from  time  to  time, 
but  are  mainly  confined  to  the  lower  portion  of  the  abdomen.  In 
such  cases  there  has  been,  in  all  likelihood,  a  distention  of  the 
csecum,  which  favors  an  accumulation  of  fgeces,  and  these  again 
have  acted  as  exciting  causes  to  an  inflammation ;  or  foreign 
bodies,  such  as  cherry-stones  or  concretions  of  various  kinds, 
have  become  impacted  in  the  csecum  or  the  vermiform  appendix, 
and  have  gradually  provoked  the  morbid  action. 

In  its  further  progress  the  case  exhibits  varied  features  :  it  may 
end  in  resolution,  and  hardened  fsecal  matter  is  passed;  or  the 
tenderness  in  the  iliac  fossa  may  become  greater,  and  vomiting, 
fever,  and  the  marked  signs  of  a  local  peritonitis  appear ;   or 


558  MEDICAL    DIAGNOSIS. 

ulceration  of  the  bowel,  and  more  frequently  still  of  the  appen- 
dix, may  allow  a  discharge  of  extraneous  matter  into  the  peritoneal 
cavity,  which  produces  violent  general  peritonitis ;  ov,  again,  the 
bowel  may  become  so  paralyzed  that  it  can  no  longer  contract  or 
propel  its  contents,  and  the  patient  dies  with  all  the  distressing 
signs  of  intestinal  obstruction. 

Now,  the  first  question  that  arises  is  \\'liethcr  we  can  distinguish 
the  inflammation  of  the  appendix  from  an  infiamination  of  the 
csecum,  both  of  which  are  mostly  included  under  the  name  typh- 
litis, though  it  is  becoming  customary  to  use  the  term  ai)pendicitis 
where  the  iuflammation  affects  only  the  appendix,  and  to  speak 
of  typhlitis  where  the  caecum  alone,  or  it  with  the  appendix,  is 
the  seat  of  disease.  There  is  no  certainty  in  the  diagnosis.  But 
these  facts  will  often  aid  us  greatly.  Most  of  the  cases  of  inflam- 
mation of  the  caecum  are  due  to  impacted  faeces,  and  the  history 
of  preceding  long-continued  constipation,  a  resisting  elongated 
mass  in  the  right  groin,  slight  pain,  and  absent  fever,  are  very 
significant.  Then,  perforating  inflammation  of  the  caecum  is  very 
rare,  while  perforation  of  the  appendix  is  of  frequent  occurrence. 
Inflammation  of  the  appendix  in  Mdiich  perforation  does  not  hap- 
pen, or  prior  to  perforation,  cannot  be  recognized. 

A  yet  more  important  question  is  whether  there  are  any  symp- 
toms which  indicate  that  perforation  of  the  appendix  has  taken 
place.  The  most  constant  and  the  first  decided  symptom  is  sudden, 
severe  abdominal  pain.  It  occurred  in  eighty-four  per  cent,  of 
the  cases  which  Fitz  in  his  admirable  essay  has  analyzed.*  The 
pain  is  mostly  at  first  in  the  right  iliac  fossa,  and  is  followed  by 
tenderness  which  gradually  extends.  It  may  be  accompanied  by 
a  chill,  but  I  have  known  it  absent  where  a  chill  was  very  de- 
cided. Fever,  with  a  temperature  of  between  100°  and  102°,  is 
next  observed ;  but  it  is  not  constant,  for  I  have  met  with  a  tem- 
perature nearly  normal  in  a  case  in  which  a  gangrenous  perforation 
of  the  appendix  was  found.f  A  circumscribed  resisting  swelling 
in  the  right  iliac  fossa,  which  forms  in  from  two  to  five  days, 
with  impaired  resonance  on  percussion,  and  a  sense  of  fluctuation 
from  the  abscess  that  develops,  and  disturbed  micturition,  estab- 


"  Transact.  Assoc.  Anier.  Phy>.,  1886. 
f  Seen  with  Dr.  Morton. 


DISEASES   OF   THE   INTESTINES   AND    PERITONEUM.        559 

lish  the  diagnosis.  A  rectal  examination  may  aid  us  in  detecting 
the  tumor,  but,  as  I  know  from  experience,  is  not  absolutely  to  be 
depended  on  as  a  means  of  recognizing  the  swelling  or  the  pus 
that  has  formed.  In  the  majority  of  cases  general  jDcritonitis 
begins  on  the  second  to  the  fourth  day  after  the  perforation.  The 
cases  that  die  from  shock  die  before  the  second  day ;  but,  as  a 
rule,  the  collapse  comes  on  more  slowly  than  in  other  forms  of 
perforative  peritonitis. 

Inflammation  of  the  loose  areolar  tissue  around  the  ceecum 
presents  much  the  same  symptoms  and  signs  as  typhlitis.  This 
perityphlitis  is,  in  truth,  frequently  combined  with  inflammation 
of  the  csecum  or  its  appendix.  Even  where  perforation  has 
taken  place,  the  matters  may  be  detained  in  the  neighborhood  of 
the  lesion,  giving  rise  to  circumscribed  inflammation  around  the 
CEecum,  and  to  an  abscess.  Subsequently  the  collection  of  pus 
may  find  its  way  into  neighboring  viscera,  or  be  discharged  exter- 
nally, when  the  ruptured  intestine  may  heal ;  although  sometimes 
the  perforation  remains  open,  and  faecal  matter  is  found  oozing 
through  the  abdominal  parietes.  The  tumefaction  which  the 
abscess  occasions,  whether  it  be  or  be  not  connected  with  disease 
of  the  intestine,  is  generally  very  evident.  When,  however,  the 
pus  burrows  under  the  iliac  fascia,  the  swelling  may  be  slight. 
But  under  such  circumstances  there  appears  a  characteristic  sign  : 
the  pain,  on  moving  the  right  foot,  is  intense,  because  the  iliac 
muscles  become  involved  in  the  disorder.  If  the  swelling  be 
great,  there  may  be  oedema  of  the  foot  and  numbness  of  the 
thigh,  from  the  pressure  on  the  vein  and  nerves.  It  is,  however, 
possible  for  inflammation  in  these  parts,  for  a  perityphlitis,  to 
terminate  by  slow  resolution,  without  the  formation  of  pus. 

When  these  abscesses  in  the  right  iliac  fossa  are  not  combined 
with  disease  of  the  adjoining  bowel,  when,  in  other  words,  they 
are  purely  perityphlitic,  they  give  rise  to  but  slight  fever  and 
pain ;  the  action  of  the  intestine  is  not  materially  interfered  with  ; 
there  is  no  nausea ;  they  are  slow  in  their  development ;  and,  as 
the  abscesses  frequently  have  a  favorable  termination  by  dis- 
charging into  the  intestine,  or  through  the  abdominal  parietes,  or 
are  very  amenable  to  treatment,  we  do  not  observe  acute  peritonitis 
supervening  on  them,  as  it  does  so  often  on  ulcerative  disease 
of  the  appendix  or  the  caecum.     Yet  there  are  cases  in  which 


560  MEDICAL    DIAGNOSIS. 

judgment  is  held  in  suspense ;  in  which  it  cannot  be  said  whether 
the  swelling  docs  or  docs  not  communicate  with  the  bowel. 

Independently  of  the  difficulty  of  distinguishing  between  the 
inflammatory  disorders  of  this  portion  of  the  alimentary  tube  and 
its  surroundings,  there  are  sources  of  perplexity  introduced  by 
the  circumstance  that  other  diseases  of  the  ca3cum  and  affections 
of  adjacent  structures  may  simulate  typhlitis  and  perityphlitis. 
Thus,  distention  and  cancer  of  the  crecum ;  inflammation  and 
ulceration  of  the  ileum ;  suppuration  of  the  kidney  or  its  en- 
velopes ;  psoas  abscess ;  abscesses  of  the  abdominal  walls ;  in- 
tussusception of  the  intestine ;  and  inflammation  of  the  ovary, — 
occasion  some  of  them  pain  and  tenderness  in  the  right  iliac  fossa, 
some  of  them  a  fulness  in  this  region  ;  therefore  all  of  them  have 
signs  which  they  share  with  an  inflammation  of  the  caecum.  But, 
although  they  all  offer  points  of  similitude,  they  also  offer  points 
of  contrast. 

A  distention  of  the  csecum  gives  rise  to  fulness  in  the  right  iliac 
fossa,  and  to  pain,  but,  unless  associated  with  inflammation,  not 
to  tenderness  or  to  fever;  copious  enemata,  too,  or  purgatives, 
clear  out  the  faeces  which  accumulate  from  A\'ant  of  power  of  the 
bowel  to  propel  them,  and  the  dulness  on  percussion  vanishes 
after  the  free  evacuations.  Another  element  of  distinction  is 
furnished  by  the  circumstance  that  those  who  suffer  from  atony 
of  this  portion  of  the  alimentary  tube  labor  under  it  for  a  long 
time  ;  they  are  generally  highly  nervous  persons,  of  sallow  com- 
plexion and  w^ith  impaired  digestion,  whose  bowels  are  habitually 
constipated,  and  who  complain  of  attacks  of  spasmodic  pain  and 
fulness  in  the  iliac  region.  Yet,  although  there  is  fulness,  there 
is  no  dulness  on  percussion,  and  no  hard  swelling  is  d'etected, 
unless  the  csecum  be  loaded  with  fseces.  On  the  contrary,  the 
c^cum  and  ascending  colon  generally  show,  by  the  excessive  tym- 
panitic resonance  when  they  are  percussed,  that  they  are  distended 
with  flatus. 

In  that  rare  disease,  cancer  of  the  csecum,  there  is  a  fixed,  firm 
swelling;  but  it  is  of  very  gradual  growth,  and  the  disorder 
generally  produces  a  stricture  of  the  bowel,  and  is  associated  with 
malignant  disease  in  other  parts  of  the  body.  Ulceration  of  the 
ileum  produces  pain  and  "tenderness  in  the  iliac  fossa.  But,  com- 
bined as  it  generally  is  with  phthisis  or  with  typhoid  fever,  the 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        561 

liistory  of  the  case  gives  a  clue  to  the  probabk;  nature  of  the 
malady.  Moreover,  there  is  not  present  a  tumefaction  which 
sounds  dull  on  percussion.  Should,  however,  perforation  of  the 
bowel  take  place  before  the  patient  is  seen,  and  general  peri- 
tonitis come  on,  the  diagnosis  is  not  so  readily  made,  because 
we  are  deprived  of  the  decisive  proof  furnished  by  the  hard 
swelling. 

As  regards  tumors  of  the  kidney  and  abscesses  in  it  or  connected 
loith  its  envelopes,  the  situation  of  the  swelling  is  not  exactly  in 
the  ileo-csecal  region,  or  at  all  events  it  is  not  confined  to  this  spot. 
The  mass  of  the  tumor  lies  in  the  loin,  or  above  the  anterior 
termination  of  the  crest  of  the  ilium  ;  and  the  urine  contains 
ingredients,  such  as  pus,  or  blood,  or  heavy  deposits  of  urates 
or  phosphates,  which  show  that  the  secretion  of  the  kidney  is 
abnormal. 

An  inflammation  in  or  about  the  right  ovary  gives  rise  to  pain 
and  tenderness  in  the  right  iliac  region,  and  to  fever.  But  it  is 
attended  with  disturbance  of  the  uterine  functions,  and  occasions 
no  very  perceptible  swelling.  A  tumor  of  the  ovary  or  of  the 
uterus  may  produce  a  visible  tumefaction ;  but,  springing  as  it 
does  out  of  the  pelvis,  its  exact  seat,  its  bulk,  its  shape,  the 
absence  of  marked  intestinal  symptoms,  and  a  per  vaginam  ex- 
amination, will  permit  its  cause  to  be  discovered. 

An  invagination  of  the  intestine  has  a  different  history,  and 
makes  its  appearance  suddenly  with  such  peculiar  signs  that, 
although  it  may  be  likcAvise  the  occasion  of  a  tumor  in  the  right 
iliac  region,  it  can  generally  be  distinguished  from  csecal  disease. 
Yet,  where  the  latter  leads  to  intestinal  obstruction,  the  diagnosis 
is  not  always  obvious ;  and  tenesmus  and  discharge  of  bloody 
mucus  from  the  rectum  may  happen  in  appendicitis. 

So,  too,  it  is  with  abscesses  in  or  near  the  region  in  which  those 
connected  with  the  csecum  occur.  Their  discrimination  is  far  from 
being  invariably  an  easy  matter.  An  abscess  in  the  abdominal  walls 
furnishes  very  many  of  the  signs  of  abscess  around  the  caecum. 
The  most  trustworthy  source  of  distinction  is,  that  the  former 
is  unassociated  with  intestinal  irritation,  while  the  latter,  from 
its  being  often  connected  with  an  affection  of  the  caecum,  is  not 
uncommonly  so  combined.  Then  the  pus  discharged  is,  for  the 
same  reason,  in  some  cases  very  offensive,  and  of  fascal   odor. 

36 


562  MEDICAL    DIAGNOSIS. 

Abscesses  in  t\\v  aluldininal  walls  arc  sometimes  symptomatic 
of  a  moi'c  distant  lesion,  as  of  caries  of  a  rib.* 

Now,  this  character  of  the  pus  ■would  equally  serve  as  a  most 
valuable  difiPerential  mark  between  the  matter  which  finds  its  way 
to  the  surface  from  a  ctecal  and  from  a  psoas  abscess.  But,  as  it 
is  not  constant,  we  have  to  apply  other  tests  to  the  recognition  of 
a  jjsoas  abscess.  A  psoas  abscess  is  associated  with  caries  of  the 
vertebrte  :  an  excurvation  of  the  spine,  dorsal  pain  and  tenderness, 
testifv  to  this  connection.  It  occurs  in  scrofulous  persons,  and, 
although  gradual  in  its  formation,  is  often  sudden  in  its  mani- 
festation; for  not  unusually  a  fluctuating,  painless  tumor  a])pcars 
below  Poupart's  ligament  as  the  first  ])ositive  sign  of  this  formi- 
dable affection.  Yet  preceding  the  pointing  of  the  abscess  at  this 
spot  there  are  often  indications  of  irritation  in  those  muscles  in  the 
sheath  of  which  the  pus  travels;  there  is  difficulty  in  extending  the 
leg;  an  inability  to  stand  upright;  and  a  dull,  uneasy  sensation 
in  the  loins,  which  the  patient  persists  in  regarding  as  rheumatic. 
Of  all  these  signs,  there  are  none  more  important,  as  sources  of 
distinction,  than  the  seat  of  the  visible  abscess  and  lits  painless 
nature.  The  interference  with  the  movements  of  the  right  leg  is 
not  so  valuable  a  sign  as  it  appears  at  first  sight  to  be;  since  when 
the  iliac  muscle  is  involved  the  same  difficulty  in  moving  the  limb 
may  exist;  and  the  iliac  muscle  may  be  implicated  in  an  inflam- 
mation of  the  loose  areolar  tissue  around  the  crecum  by  the  in- 
flammation extending  to  the  iliac  fascia  and  causing  pus  to  collect 
under  it :  what  surgeons  term  iliac  abscesses  arc,  indeed,  collec- 
tions of  pus  under  this  fascia.  And,  in  point  of  fiict,  they  not 
unfrequently  originate  near  the  csecum,  or  spread  to  the  tissues 
surrounding  this  portion  of  the  bowel,  break  into  the  cavity  of 
the  peritoneum,  and  therefore  practically  constitute  perityphlitic 
abscesses. 

Other  affections  than  those  of  the  boM'cls  may  give  rise  to  phe- 
nomena supposed  to  indicate  typhlitis.  It  does  not  at  first  sight 
seem  likely  that  this  would  be  the  case  with  pneumonia.  Yet 
the  mistake  has  been  committed.  Pain  is  sometimes  referred  to 
the  right  groin  in  pneumonia,  and  there  is  soreness  there,  con- 
nected probably  M'ith  the  efforts  at  coughing  and  the  disordered 

*  Oppolzer,  Wien.  Med.  "Wochenschrift,  1862. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         563 

breathing.  Nay,  I  have  known  poultices  applied  to  the  right  iliac 
fossa  to  relieve  the  inflammation  which  really  was  in  the  chest. 
An  examination  of  this  part  of  the  body  will  of  course  at  once 
explain  the  true  character  of  the  symptoms. 


Disorders  attended  with  Constipation,  and  of  which  it  is  a 
Prominent  Symptom, 

An  inactive  state  of  the  bowels  is  often  but  a  concomitant  of 
some  disorder  which  presents  phenomena  much  more  striking  than 
the  imperfect  voidance  or  the  prolonged  retention  of  the  fseces. 
But  there  are  cases  in  which  the  constipation  is  a  very  important 
symptom,  in  which  it  constitutes  the  ailment  for  which  we  are 
consulted,  and  in  which  it  furnishes  by  far  the  most  decisive 
proof  of  a  serious  morbid  condition  of  the  intestine.  Now,  these 
cases  are  either  those  in  which  the  constipation  arises  suddenly, 
or  at  any  rate  becomes  suddenly  aggravated,  is  attended  with  se- 
vere symptoms,  and  is  often  insuperable ;  or  those  in  which  it  is  an 
habitual  state  and  not  associated  with  any  signs  of  urgent  distress. 

Intestinal  Obstruction. — Intestinal  obstruction,  when  com- 
ing on  suddenly,  manifests  itself  generally  in  the  following  man- 
ner. A  person,  previously  in  good  health,  or  perhaps  of  costive 
habit,  notices  that  his  bowels  have  not  been  moved  for  several 
days,  and  that  he  has  an  uneasy  feeling  in  the  abdomen  in  conse- 
quence. He  takes  the  purgative  he  is  wont  to  employ,  but  with- 
out the  usual  effect.  Something  more  active  is  tried,  and  still 
the  bowels  remain  obstinately  bound.  Colicky  pains  have  in  the 
mean  time  made  their  appearance.  He  becomes  alarmed,  and 
sends  for  his  physician.  On  his  arrival,  the  medical  attendant 
sees  that  there  is  indeed  cause  for  alarm.  He  finds  the  abdomen 
somewhat  distended,  but  not  painful,  or  perhaps  only  slightly 
painful,  on  pressure.  But  through  its  parietes  may  be  noticed  the 
violent,  rolling  motion  of  the  irritated  intestine.  Vomiting  sets  in, 
— first,  of  the  substances  contained  in  the  stomach  or  of  a  bilious 
fluid,  and,  as  the  case  progresses,  of  stercoraceous  matter.  In  this 
way,  unless  nature  or  art  come  to  the  rescue,  the  disease  con- 
tinues ;  and  signs  of  inflammation  of  the  bowels,  and  with  them 
fever,  appear  as  preludes  to  the  fatal  termination.  Sometimes, 
however,  the  patient  becomes  gradually  exhausted ;  there  are  no 


5G4  MEDICAL   DIAGNOSIS. 

tenderness  and  fever,  hut  a  cool  skin,  a  quick,  small  pulse,  a  coun- 
tenance, ghastly  and  panic-stricken.  Severe  paroxysms  of  jiain, 
alternating  with  intervals  of  ease,  may  occur  to  the  last  moment. 
But,  in  spite  of  the  utter  prostration,  the  mind  generally  retains 
its  clearness.  Should  recovery  take  place,  large  quantities  of  fa?cal 
matter  are  discharged,  and  all  the  symptoms  of  the  impediment 
sjiecdily  disaj>pear. 

These  phenomena  are  too  striking  to  permit  of  errors  in  diag- 
nosis. Yet  errors  are  of  frequent  occurrence,  because  the  history 
of  the  attack  and  the  sequence  of  the  symptoms  are  not  taken 
into  account.  Many  a  person  laboring  under  peritonitis  has  been 
violently  purged  to  remove  the  stubborn  constipation  believed  to 
be  due  to  a  mechanical  hinderance  in  the  bowels;  and,  on  the 
other  hand,  many  a  case  of  intestinal  obstruction  has  been  treated 
solely  witli  reference  to  the  inflammation  which  may  attend  it,  and 
without  regard  to  the  source  of  the  inflammation.  Yet  it  is  not 
ordinarily  difficult  to  distinguish  which  is  cause  and  M'hich  effect. 
A  case  that  begins  with  colicky  pains  and  obstinate  constipation, 
in  which  at  first,  in  spite  of  the  pain,  there  is  little  or  no  tender- 
ness ;  in  ^^•hich  the  thermometer  does  not  indicate  materially- 
raised  temperature  ;  in  which  vomiting  and  tympany  soon  occur ; 
in  which  fulness  on  palpation  and  dulness  on  percussion  may  be 
detected  at  or  above  the  point  of  stoppage ;  and  in  which  ftecal 
matter  is  ejected  by  the  mouth  after  a  stoppage  of  the  bowels 
of  a  few  days'  duration, — is  not  primarily,  whatever  may  be  the 
ultimate  complications,  enteritis  or  peritonitis.  A  case  presenting 
almost  from  the  onset  fever  and  great  and  extended  tenderness ; 
in  which  vomiting  of  ffecal  matter,  if  it  happen  at  all,  does  not 
happen  until  late;  in  which  diarrhoea  is  sometimes  found  to  super- 
sede the  enduring  constipation, — is  inflammation  of  the  jieritoneum, 
but  not  a  mechanical  obstruction.  Only  in  very  rare  instances, 
and  especially  when  the  bowel  is  invaginated,  is  the  malady  so 
quickly  succeeded  by  inflammation  as  seemingly  to  make  its  ap- 
pearance with  the  signs  of  2)eritonitis.  On  the  other  hand,  per- 
forative jieritonitis,  with  its  symptoms  of  collapse,  shows  a  much 
stronger  likeness  to  acute  obstruction  of  the  bowel  than  ordinary 
peritonitis  does. 

The  symptoms  dwelt  upon  as  pointing  to  an  intestinal  obstruc- 
tion bear  a  close  resemblance  to  those  of  external  strangulated 


DISEASES    OF   THE    INTESTINES    AND    PERITONEUM.         565 

hernia.  In  truth,  they  not  only  resemble  but  are  identical  with 
those  of  this  affection.  Hence,  in  every  case  of  obstinate  consti- 
pation, each  point  which  may  be  the  seat  of  a  hernia  must  be 
explored  by  the  eye  and  the  hand.  No  motives  of  false  delicacy, 
no  reluctance  on  the  part  of  the  patient,  should  prevent  the  prac- 
titioner from  insisting  on  a  search,  the  neglect  of  which  may  cost 
a  life. 

It  would  be  foreign  to  the  object  of  this  work  to  discuss  the 
external  signs  by  which  a  strangulation  of  the  intestine  at  a  her- 
nial opening  manifests  itself.  It  need  only  be  mentioned  that  it 
is  at  the  groin,  at  the  umbilicus,  at  the  side  of  the  anus,  or  through 
the  ischiatic  notch  that  the  gut  descends  and  forms  a  tumor,  and 
that  these  are,  therefore,  the  regions  to  be  scrutinized.  But  there 
is  one  part  of  the  subject,  of  importance  alike  to  the  physician  and 
to  the  surgeon,  which  cannot  be  passed  by  without  a  few  words, 
since  it  may  be  a  cause  of  much  perplexity, — namely,  the  possi- 
bility of  intestinal  obstruction  taking  place  in  a  person  laboring 
under  an  irreducible  hernia  and  simulating  strangulation  without 
any  strangulation  having  occurred.  Of  this  the  following  case 
furnishes  an  example. 

In  October,  1857,  I  was  requested  by  a  physician  to  see  with 
him  a  person,  the  mother  of  thirteen  children,  who  had  been  for 
several  days  laboring  under  obstinate  constipation.  Large  doses 
of  mercurials,  croton  oil,  and  turpentine  enemata  had  failed  to 
procure  a  passage,  and  the  patient  was  becoming  much  frightened 
about  herself.  ISTor  was  her  situation  free  from  danger.  She  had 
considerable  pain  in  the  abdomen ;  she  had  been  vomiting  sterco- 
raceous  matter  profusely ;  the  rolling  of  tlie  intestines  could  be 
plainly  perceived.  On  her  right  side  was  a  small  irreducible 
femoral  hernia,  which.,  on  inquiry,  was  found  to  have  existed  for 
many  years.  It  was  not  painful  on  pressure,  nor  was  the  skin 
covering  it  discolored ;  neither  did  the  mass  itself  communicate 
an  impulse  during  the  act  of  coughing.  Here  were  signs  of  a 
serious  impediment  to  the  onward  passage  of  the  intestinal  con- 
tents, as  the  fsecal  vomiting  and  the  rolling  of  the  intestines 
showed  plainly.  But  was  it  due  to  strangulation  at  the  hernial 
opening  ?     Was  it  an  internal  intestinal  obstruction  ? 

An  accurate  examination  of  the  abdomen  did  not  throw  much 
light  on  these  questions.     The  belly  was  moderately  tympanitic, 


506  MEDICAL    DIAGNOSIS. 

and  not  painful  to  the  touch,  except  when  the  pressure  was  con- 
siderable. The  rolling  ol"  the  intestines  was  perhaps  more  obvi- 
ous on  the  left  side  ;  but  nowhere  could  a  tumor  be  felt.  Taking 
all  the  circumstances  of  the  case  into  account, — the  fact  that  the 
patient  was  of  costive  habit ;  that  she  was  subject  to  attacks  of 
colic  and  of  obstinate  constipation ;  that  there  was  nothing  to 
prove  that  the  hernia  had  recently  increased,  or  was  in  any  way 
inflamed, — I  was  led  to  the  conclusion  that  the  case  was  not  one 
of  hernial  strangulation,  but  of  internal  intestinal  obstruction  ; 
and  she  was  treated  for  this.  Copious  Marni-watcr  injections 
were  thrown  into  the  colon  through  a  flexible  tube ;  her  abdo- 
men was  rubbed  Avitli  mercurial  ointment.  But  all  in  vain  :  she 
continued  vomiting  fsecal  matter. 

Her  situation  now  appeared  desperate.  She  had  not  had  a 
passage  for  six  days;  remedies  had  failed  to  procure  her  one;  she 
was  steadily  sinking.  Knowing  that  sometimes  the  gut  may  be 
strangulated  at  a  hernial  opening  without  much  pain  or  tender- 
ness, the  counsel  of  an  eminent  surgeon  was  sought,  to  aid  in 
determining  whether  this  was  not  the  cause  of  the  impediment. 
He  thought  it  probable  that  it  was,  and  proposed  an  operation,  to 
which  consent  was  reluctantly  obtained.  The  patient  was  ether- 
ized, and  the  hernial  section  rapidly  and  skilfully  performed  ;  but 
no  constriction  was  found.  The  wound  was  closed,  and  large 
doses  of  opium  were  administered,  so  as  to  mitigate,  as  far  as 
practicable,  the  torturing  distress  of  the  only  termination  to  the 
case  which  seemed  possible.  On  the  day  after  the  operation,  the 
intestines  had  ceased  to  roll ;  there  was  no  vomiting.  But  sterco- 
raceous  vomiting  reappeared  two  days  afterward,  and  the  rolling 
of  the  intestines  was  occasionally,  although  faintly,  perceptible. 

The  patient's  exhaustion  was  now  extreme;  her  pulse  was  very 
quick  and  small ;  her  skin  cold,  of  a  dirty  look  ;  the  odor  of  the 
breath  and  of  the  wdiole  body  offensive ;  and  the  eyes  sunken 
and  surrounded  by  a  broad  leaden  ring.  There  was  slight  pain 
on  pressure  between  the  umbilicus  and  the  sigmoid  flexure.  The 
vomiting  had  ceased,  or  occurred  only  very  occasionally.  Al- 
though there  \\'as  little  hope,  we  had,  as  soon  as  admissible  after 
the  operation,  recommenced  rubbing  mercurial  ointment  over  the 
abdomen,  and  giving  injections  in  the  manner  before  described. 
This  was  continued  until,  to  our  great  gratification,  one  morning, 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         5G7 

after  a  tube  had  been  passed  a  distance  of  several  feet  into  the 
colon,  the  patient  had  a  copious  discharge  of  tarry  fajf-al  matter 
from  her  bowels, — seventeen  days  after  the  symptoms  of  complete 
intestinal  obstruction  had  declared  themselves  by  the  occurrence 
of  stercoraceous  vomiting. 

This  case  is  instructive  in  more  than  one  respect.  It  teaches 
that  recovery  may  take  place  most  unexpectedly  after  the  patient 
has  been  kept  at  death's  door  for  many  days ;  and,  in  a  diag- 
nostic point  of  view,  it  illustrates  a  difficulty  which  any  physician 
may  have  to  encounter  in  attending  a  patient  the  subject  of  a 
long-standing  hernia. 

Supposing  that  the  symptoms  are  altogether  owing  to  an  ob- 
stacle at  some  portion  of  the  intestine  within  the  abdomen :  can  we 
determine  the  exact  position  of  the  impediment,  and  its  nature  ? 
We  know  how  varied  are  the  conditions  which  lead  to  sudden 
and  invincible  constipation.  We  know  that  intussusceptions, 
twists,  displacements,  strictures,  bands  and  adhesions,  or  gaps 
in  the  omentum,  foreign  bodies,  impacted  fseces,  gall-stones,  and 
spasmodic  contraction  of  the  intestine,*  may  all  occasion  intestinal 
obstruction,  and  some  of  these  states  even  internal  strangulation. 
We  also  know  that  in  certain  cases  the  obstruction  is  congenital.f 
Can  we  distinguish  these  diiferent  lesions  at  the  bedside?  In  cer- 
tain cases  we  can, — we  can  determine  exactly  both  the  position 
and  the  character  of  the  lesion ;  in  others  there  is  no  clue  to  an 
accurate  discernment  of  either.  From  the  method  of  the  introduc- 
tion of  the  whole  hand  into  the  rectum  much  has  been  expected. 
But  experience  has  not  confirmed  these  expectations.  In  three 
cases  of  intestinal  obstruction  examined  by  Walshami  the  hand 
in  all  failed  to  detect  a  lesion.  Obstruction  of  the  bowel  may 
clinically  present  itself  as  an  acute  or  as  a  chronic  malady.  The 
same  symptoms  occur  in  both.  It  is  the  mode  of  origin  which  is 
different.  Nay,  the  same  lesion  may  occasion  in  some  instances 
an  acute,  in  others  a  chronic,  aflPection.  Invagination,  internal 
strangulation,  volvulus,  impaction  of  a  large  gall-stone,  are  gener- 
ally acute ;  strictures,  contractions,  and,  for  the  most  part,  faecal 
accumulation,  lead  to  chronic  obstruction. 

*  Archives  Generales,  Aug.  1868. 

t  Gould,  Transact.  Clin.  Soc.  Loud.,  1882. 

X  St.  Bartholomew's  Hospital  Reports,  1876. 


668  MEDICAL   DIAGNOSIS. 

Of  the  causes  of  intestinal  obstruction,  infussusccjMonoY  invar/i- 
nnUon  is  tlie  most  frequent  and  at  the  same  time  the  least  diftieult 
of  recognition  during  life.  Part  of  the  bowel  becomes  inverted, 
slijiping  into  the  cavity  of  the  adjoining  upper  or  lower  portion. 
Inflammation  is  soon  set  uji,  produces  infiltration  of  the  tissues, 
and  often  leads  to  adhesions  between  the  opposed  serous  surfaces, 
and  to  effusions  of  blood  and  mucus  into  the  canal.  The  swelling 
blocks  up  the  tube ;  yet  it  does  Jiot  of  necessity  do  so.  The  in- 
flammation may  spread  rapidly  over  the  serous  membrane,  and 
the  patient  may  die  from  general  peritonitis.  But  sometimes  in 
this  inflammation  that  is  lighted  up  at  the  seat  of  the  ileus  lies 
safety.  It  may  give  rise  to  adhesive  inflammation  of  the  opposed 
serous  coats  of  intestine,  and  ultimately  to  a  sloughing  ofP  of  the 
invaginated  part  and  its  discharge  into  tlie  bowel,  while  the 
annular  mass  of  adhesive  lymph  surrounding  the  seat  of  ulcer- 
ation maintains  the  continuity  of  the  intestinal  canal,  and  thus  the 
inflammation  may  pave  the  way  to  a  favorable  issue  by  restoring 
the  calibre  of  the  tube, — sufficiently,  at  any  rate,  to  permit  of  the 
transit  of  its  contents. 

These  pathological  peculiarities  develop  special  symptoms  which 
frequently  enable  us  to  determine  the  nature  of  the  obstruction. 
When  the  intussusception  takes  place  rapidly,  a  sudden  local  pain 
is  produced,  recurring  in  paroxysms,  and  likely  to  be  referred  to 
the  seat  of  the  disturbance.  The  pain  is  quickly  followed  by  vom- 
iting, by  constipation,  by  tympany,  and  by  peritonitis.  But  the 
constipation  is  not  so  absolute  as  in  other  cases  of  intestinal  im- 
pediment. Not  unusually,  in  fact,  owing  to  the  invaginated  bowel 
remaining  open,  the  liquid  contents  of  the  intestine  pass  through 
the  intussuscepted  part  and  produce  a  deceptive  diarrhoea;  yet 
oftener  will  occur  tenesmus,  and  discharges  of  the  bloody  mucus 
and  serum  which  have  accumulated  in  the  intestine.  Both  of  the 
latter  signs  are  eminently  diagnostic  of  the  lesion.  Still  more  so 
is  feeling  the  end  of  the  invaginated  bowel  by  an  exploration  of 
the  rectum,  or  finding  the  loosened  segment  in  the  stools.  But  it 
is  only  in  cases  in  which  the  lower  portion  of  the  canal  is  affected, 
or  which  have  been  sufficiently  protracted  to  allow  of  the  curative 
efforts  of  nature  being  accomplished,  that  signs  so  pathognomonic 
are  met  with. 

The  casting  off  of  the  sloughed  portion  of  the  intestine  is 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         5G9 

attended  with  hemorrhage.  Whether  this  be  tlie  only  cause  of 
the  hemorrhage  or  not,  it  is  undoubted  that  purging,  or  some- 
times vomiting,  of  blood,  is  among  the  differential  signs  of  intus- 
susception. A  sign  more  valuable,  because  so  much  more  common, 
is  the  presence  of  a  tumor.  Its  seat  varies  with  the  seat  of  the 
lesion.  And  as  the  most  frequent  invaginations  are  those  of  the 
ileum  and  caecum  into  the  colon,  or  those  at  the  inferior  portion 
of  the  ileum,  it  is  at  the  lower  part  of  the  belly,  and  generally 
passing  in  direction  from  left  to  right,  and  in  the  right  iliac  fossa, 
that  the  swelling  is  detected,  and  often  it  may  be  felt  through  the 
rectum.  The  malady  occurs  at  all  ages.  It  is  often  preceded 
by  diarrho3a.  Sometimes  it  is  caused  by  tumors  of  the  intestine, 
particularly  by  lipoma.* 

Most  cases  of  invagination  occur  under  thirty  years  of  age. 
The  course  the  affection  pursues  is  rapid.  The  acute  inflamma- 
tion it  occasions  soon  leads  to  a  fatal  termination,  or  the  patient 
dies  generally  in  less  than  a  week  after  the  occurrence  of  the  acci- 
dent, utterly  prostrated.  Yet  the  records  of  medicine  furnish  us 
with  instances  in  which  life  has  been  prolonged  for  months.  The 
cases  which  get  well  recover  either  gradually  after  the  invaginated 
bowel  has  been  discharged,  or,  in  very  rare  instances,  more  quickly 
by  the  inverted  bowel  righting  itself. 

Acute  obstruction  from  volvulus  or  twist  begins  with  severe 
abdominal  pain,  soon  becomes  associated  with  nausea  and  vomit- 
ing, and  rarely  presents  a  tumor  or  visible  intestinal  coils  or 
elevation  of  temperature,  f 

As  regards  other  forms  of  intestinal  obstruction,  they  are,  with 
our  present  knowledge,  undistinguishable  from  one  another. 
However  desirable  it  might  be  on  therapeutic  grounds  to  be 
able  to  diagnosticate  a  blocking  up  of  the  intestine  by  hardened 
faeces  or  gall-stones,  or  its  strangulation  by  bands  or  by  rents  in 
the  mesentery ;  however  desirable  to  know  w^hether,  if  medical 
means  do  not  bring  relief,  the  operation  of  laying  open  the  belly 
may  be  attempted  with  hope  of  success,  or  whether  the  impediment 
is  not  even  to  be  removed  by  such  a  mode  of  succor, — it  must  be 


*  Clos,  De  I'Invagination  intestinale,  etc.,  Paris,  1883. 

t  Fitz,  Acute   Intestinal   Obstruction,  Transact,  of  Congress  of  American 
Pliysicians  and  Surgeons,  vol.  i.,  1889. 


o70  MKDICAL    DIAGNOSIS. 

confessed  that  there  are  few  signs  which  enable  us  positively  to 
decide  on  the  nature  of  the  obstacle. 

Yet  tl>ere  are  sometimes  circumstances  in  the  case  which  help 
to  a  correct  decision.  For  example,  if  the  complaint  occur  in 
one  who  has  suffered  from  the  passage  of  gall-stones,  especially  in 
a  fat,  elderly  A\oman,*  it  is  likely  that  a  large  concretion  of  this 
kind  has  been  arrested  in  its  passage  through  the  small  intestine. 
Should  the  disorder  be  encountered  in  a  ]>erson  over  forty  years  of 
age,  who  at  all  times  has  difficulty  in  voiding  the  contents  of  the 
tube ;  whose  fa}ces  })resent  jieculiai'itics  in  shape  and  size,  and  are 
sometimes  mixed  with  blood ;  whose  health  has  been  gradually 
breaking;  whose  abdomen  is  much  distended  and  yields  a  ringing 
tympanitic  resonance  on  percussion, — should  such  a  person  have  an 
attack  of  constii)ation  unusually  protracted,  attended  with  enor- 
mous distention  of  the  boAvel,  and  in  which  the  remedies  that 
hitherto  barely  procured  a  passage  now  fail  utterly,  it  would  not 
require  much  sagacity  to  discern  that  a  stricture  of  the  intestine, 
probably  of  a  cancerous  kind,  is  the  source  of  the  cruel  and  irre- 
mediable suffering.  If,  in  addition  to  the  symptoms  enumerated, 
a  bougie  passed  into  the  rectum  meet  in  its  course  with  a  decided 
obstacle,  an  error  in  diagnosis  is  hardly  possible.-  When,  how- 
ever, the  stricture  is  not  accessible  to  instrumental  examination, 
although  we  can  commonly  recognize  its  presence,  we  cannot  fix 
its  site.  The  distention  above  the  narrowed  part  is  often  so  ex- 
treme as  to  lead  to  displacement  of  the  colon  and  to  an  almost 
uniform  swelling  of  the  whole  abdomen.  For  instance,  in  a  casQ 
reported  by  Albert  H.  Smith,  the  enormously-dilated  colon  had 
broken  loose  from  its  attachments  and  concealed  the  rest  of  the 
viscera.  It  was  in  several  places  eighteen,  in  none  less  than 
fifteen,  inches  in  circumference ;  and  fully  two  gallons  of  liquid 
faeces  ^vere  found  in  the  bowels.f 

In  the  majority  of  cases  the  stricture  is  either  in  the  rectum  or  in 
the  sigmoid  flexure.  A  contraction  in  the  small  intestine  similar 
to  the  true  stricture  of  the  large  bowel  is  seen  chiefly  as  the  result 
of  chronic  peritonitis  binding  doMn  the  bowel,  and  may  lead,  like 
a  stricture,  to  chronic  obstruction.^      Fsecal  accumulations  also 

*  Fagge,  Practice  of  Medicine,  vol.  ii.  p.  210. 

t  Proc.  of  Pathol.  Soc.  of  Phila.,  Dec.  18;i8,  vol.  i. 

X  Fagge,  Guy's  Ho?p.  Picp.,  3d  Series,  vol.  xiv. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.       .571 

produce  chronic  obstruction.  We  distinguish  this  form  chic-fly 
by  its  occurrence  in  women,  especially  hysterical  women,  or  in 
hypochondriacs,  by  the  tenderness  over  the  fiecal  tumors,  the 
gradually-increasing  constipation,  the  late  occurrence  of  pain  and 
of  vomiting,  and  the  extreme  foulness  of  the  breath.* 

In  any  kind  of  obstruction  the  location  of  the  lesion  is  difficult  to 
determine.  There  are,  however,  a  few  circumstances  which  may 
aid  us  in  arriving  at  such  a  determination  :  one  is  the  fact  pointed 
out  by  Barlow, t  that  the  higher  up  the  obstruction  is  in  the  canal, 
the  nearer  therefore  to  the  stomach,  the  smaller  is  the  quantity  of 
•  urine  passed  ;  another  is  the  early  occurrence  of  the  vomiting  and 
the  want  of  stercoraceous  character  of  the  matters  ejected, — both 
of  which  render  it  likely  that  the  impediment  is  in  the  small 
intestine  and  remote  from  the  csecum.  Still  another  is  the  speedy 
presence  and  the  greater  severity  of  hiccough  when  the  mischief 
is  in  the  small  intestine.  Sometimes  the  patient  is  himself  aware 
of  the  exact  seat  of  the  cause  of  his  suffering ;  he  notices  that  the 
injecting  tube  or  the  enemata  seem  to  reach  a  certain  point  and 
go  no  farther;  so,  also,  with  the  rumbling  of  the  wind.  Again, 
these  borborygmi  are  especially  apt  to  occur  in  obstructions  of 
the  large  intestine,  and,  if  joined  to  tenesmus,  are  signs  of  some 
importance.  Indican  is  found  in  the  urine  in  greatly-increased 
quantities  in  stoppages  of  the  small  intestine.  We  may  also  be 
able  to  come  to  some  conclusion  about  the  seat  of  the  lesion  by 
inflating  the  large  intestine,  or  by  finding  out  how  many  quarts 
of  warm  water  we  can  inject  into  it. 

The  position  of  the  pain,  too,  may  furnish  a  clue  to  the  position 
of  the  impediment.  If  this  be  in  the  small  intestine,  the  pain  is 
apt  to  be  chiefly,  if  not  entirely,  in  the  neighborhood  of  the  um- 
bilicus. Another  circumstance  on  which  some  stress  may  be  laid 
is  the  distention  of  the  intestine  above  the  point  of  intusussception. 
Indeed,  this  distention  may  occasion  a  visible  fulness,  sounding 
extremely  tympanitic  on  percussion  ;  at  times,  too,  a  slight  dulness 
is  found,  attended  with  some  resistance  at  or  immediately  above 
the  seat  of  the  obstruction.     But  Avith  reference  to  the  swellinp" 

*  Treves,  Lancet,  Oct.  29,  1887. 

t  Guy's  Hosp.  Kep.,  2d  Series,  vol.  ii.  Brinton  accepts  this  statement  only 
in  so  far  as  the  amount  of  vomiting,  which  is  apt  to  be  greatest  when  the 
obstruction  is  high  up,  influences  the  amount  of  urine  passed. 


572  MEDICAL    DIAGNOSIS. 

and  the  tympanitic  dilatation  of  the  bowel  there  are — as  William 
Brinton*  sets  forth — several  reasons  which  render  these  signs  un- 
certain guides.  The  distended  intestine  may  not  be  capable  of 
being  traced  by  the  eye  or  by  percussion,  OM'ing  to  its  occupying 
a  large  portion  of  the  abdominal  cavity.  Moreover,  a  stoppage 
at  the  descending  part  of  the  large  intestine,  for  instance  at  the 
sigmoid  flexure,  may  lead  to  most  palpable  distention  of  the 
ciecum,  and  to  pain  in  that  region  ;  Avhile  pain  and  swelling  are 
also  observed  in  the  same  locality  in  obstructions  which  affect  the 
small  intestine.  Thus  there  are  several  modifying  circumstances 
■which  prevent  too  much  importance  being  attached  to  any  of  the 
signs  mentioned  as  proofs  of  the  seat  of  the  obstacle ;  for,  with 
the  exception  of  a  tumor  dull  on  percussion  and  resistant  to  the 
touch,  there  is  nothing  absolutely  indicative  of  the  lesion  being 
at  a  particular  spot.  It  is  hardly  necessary  to  say  that  a  swelling 
of  this  kind  cannot  always  be  found. 

Internal  strangulation — as  by  a  band  acting  as  the  constricting 
agent,  or  a  diverticulum,  or  the  pedicle  of  an  ovarian  tumor — has 
its  seat  almost  constantly  in  the  small  intestine.  Hilton  Faggef 
considers  these  symptoms  as  significant  and  as  warranting  a  diag- 
nosis of  internal  constriction :  the  sudden  onset  of  the  illness ; 
the  occurrence  of  collapse  at  its  beginning ;  the  comparatively 
early  age  of  the  patient ;  the  severity  of  the  pain,  which  is  gener- 
ally referred  to  the  umbilicus ;  the  absence  of  external  or  of  dis- 
coverable obturator  hernia  ;  the  absence  of  precursory  symptoms 
and  of  visible  peristole, — such  as  happen  in  stricture  and  contrac- 
tions,— of  tumor,  of  hemorrhage,  and  of  dysenteric  symptoms, — 
as  seen  in  intussusception, — and  of  that  extreme  intensity  and 
rapidity  of  the  disorder  which  characterize  the  more  acute  forms 
of  volvulus.  Obstruction  by  a  band  connected  with  a  diver- 
ticulum scarcely  ever  occurs  except  in  males  under  twenty  years 
of  age.J 

In  referring  to  the  usual  scat  of  pain  and  swelling  in  the  right 
iliac  fossa,  and  to  the  difficulties  which  on  this  account  beset  the 
recognition  of  the  precise  site  of  the  hinderance,  one  source  of 


*  Croonian  Lectures,  and  work  on  Intestinal  Obstruction, 
t  Guy's  Hosp.  Rep.,  3d  Scries,  vol.  xiv. 
X  Fagge,  Practice  of  Medicine,  vol.  ii. 


DISEASES   OP   THE   INTESTINES   AND    PERITONEUM.        573 

error  deserving  of  special  notice  was  not  mentioned.  The  pain 
and  the  fulness  in  this  region  may  be  caused  by  a  disease  of  the 
csecum  or  of  its  appendix.  Moreover,  affections  of  this  part  of 
the  alimentary  tract,  like  intestinal  occlusion,  give  rise  to  consti- 
pation which  is  most  obstinate  and  in  some  instances  incurable. 
Therefore  they  in  reality  enter  at  times  into  the  category  of  in- 
testinal obstructions,  from  the  other  varieties  of  which  they  are, 
under  such  circumstances,  undistinguishable  save  by  the  history 
of  the  case  and  the  different  sequence  of  the  phenomena.  The 
tumor  and  the  other  local  signs  do  not  follow  the  insuperable 
constipation,  but  they  precede  it.  Yet  if  the  patient  be  seen  for 
the  first  time  when  he  is  laboring  under  an  irremovable  in- 
testinal impediment,  it  may  be  impossible  rightly  to  determine 
its  character.  Stress  may  be  laid  upon  the  occurrence  of  chills 
as  indicative  of  the  presence  of  pus,  or  upon  the  signs  of  collapse 
in  perforative  appendicitis. 

Habitual  Constipation. — This  is  a  chronic  state,  unattended 
with  urgent  symptoms  of  any  kind.  Still,  it  is  an  annoying  and 
very  prevalent  disorder.  The  symptoms  encountered,  indepen- 
dently of  the  rare  and  difficult  fsecal  evacuations,  are  headache, 
giddiness,  sluggishness  of  the  mind,  a  want  of  the  natural  appe- 
tite, ansemia,  cutaneous  eruptions,  and,  joined  as  the  complaint  not 
unfrequently  is  to  derangement  of  the  stomach  and  of  the  biliary 
secretion,  digestive  disturbances  and  a  sallow  complexion :  an 
altered  state  of  the  blood  from  the  absorption  of  ptomaines  may 
exist.  In  women  there  are  also  often  added  to  the  list  of  evils 
to  which  costiveness  gives  rise,  neuralgic  pains,  palpitation  of  the 
heart,  cold  feet  and  hands.  Infrequent  evacuation  of  the  bowels 
does  not  always  produce  such  unpleasant  consequences.  It  may, 
indeed,  in  individual  cases  be  compatible  with  perfect  health ;  for 
what  is  costiveness  in  one  person  may  be  a  natural  state  in  another.* 
But  when  the  bowels  are  acting  less  frequently  than  is  their  wont, 
the  disagreeable  symptoms  mentioned  are. apt  to  arise. 

Habitual  constipation  is  produced  by  various  causes.  It  may 
be  brought  about  by  the  peculiar  nature  of  the  diet.  It  mav 
depend  upon  a  deficiency  or  a  faulty  composition  of  the  intestinal 

*  In  the  American  Journal  of  the  Medical  Sciences,  Oct.  1874,  a  case  is 
reported  in  which  the  constipation  lasted  eight  months  and  sixteen  days. 


574  MEDICAL    DIAGNOSIS. 

secretions,  or  upon  disorders  of  those  neighboring  ghmds  which 
pour  their  secretions  into  the  intestines.  It  may  result  from  im- 
paired power  of  the  bowel  to  })ropel  its  contents,  the  consequence 
either  of  some  mechanical  interference  with  its  action,  or  of  ner- 
vous influences,  or  of  exposure  to  the  poisonous  eifects  of  certain 
substances,  as  of  lead.  To  particularize  the  numerous  conditions 
whifh  furnish  iUustrations  of  each  of  these  different  causes  would 
serve  no  useful  purpose.     A  few  only  need  be  specially  noticed. 

We  have  often  to  treat  constipation  in  those  who  are  dyspeptic 
and  suffer  from  piles.  In  them  there  is,  in  all  probability,  some 
congestion  of  the  portal  system,  and  not  unfrequcntly  a  constant 
derangement  of  the  flow  of  blood  through  the  liver.  The  normal 
secretion  of  intestinal  juices  is  interfered  with,  healthy  bile  is  not 
supplied,  and  thus  costivencss  results.  A  similar  congestion  of 
the  intestinal  mucous  membrane  has  its  share  in  producing  the 
constipation  which  is  encountered  in  diseases  of  the  heart.  Some- 
times, however,  enough  healthy  fluid  is  poured  out  within  the 
intestine ;  yet  there  is  a  deficiency,  because  the  inclination  to  go 
to  stool  is  resisted,  and  the  liquid  that  has  been  mixed  with  the 
matter  to  be  voided  is  reabsorbed.  In  w^omen  who  neglect  the 
calls  of  nature  because  circumstances  prevent  their  being  obeyed 
at  the  proper  time,  this  is  a  common  cause  of  constipation. 

The  influence  of  the  nervous  system  on  the  alimentary  tube  is 
shown  by  the  confined  state  of  the  bowels  which  attends  excessive 
intellectual  exertion  and  violent  emotions.  And  when  these  states 
are  protracted,  they  lead  to  a  permanent  and  annoying  debility  of 
the  intestine.  The  colon  especially  becomes  torpid  in  its  action, 
and  all  the  evil  results  of  constipation  show  themselves  in  their 
most  marked  degree.  Not  that  an  atony  of  the  bowel  is  always 
due  to  psychical  agencies.  Any  disorder  which  induces  loss  of 
power  in  the  muscular  fibres  may  give  rise  to  it.  We  find  it 
where  the  blood  is  watery  and  deficient  in  red  corpuscles,  and  in 
those  who  lead,  as  far  as  bodily  exertion  is  concerned,  a  sluggish 
life.  In  some  cases — fortunately  rare — the  weak  intestine  dis- 
tends greatly,  and  becoming,  as  above  explained,  unable  to  propel 
the  accumulated  faeces,  insuperable  constipation  occurs.  The  same 
complete  paralysis  of  the  tube,  attended  with  the  same  unfortunate 
consequences,  may  be  brought  about  by  chronic  lesions  of  the  brain 
or  spinal  cord.    Yet  the  inveterate  constipation  which  is  so  constant 


DISEASES   OP   THE   INTESTINES   AND    PERITONEUM.        575 

an  accompaniment  of  these  states  is  partly  owing  to  the  powerless 
condition  of  the  abdominal  muscles. 

Among  the  different  organic  changes  in  the  intestine  which,  by 
interfering  mechanically  with  the  peristaltic  wave,  set  up  consti]3a- 
tion,  we  find  distention  of  the  tube,  with  atrophy  of  the  muscular 
fibres;  various  infiltrations  into  the  walls,  producing  a  narrowing 
of  the  calibre,  as  in  carcinoma ;  and  adhesions  between  the  serous 
coats  of  the  intestines,  or  between  these  viscera  and  the  parietes. 
Of  the  first,  it  need  only  be  said  that  the  symptoms  are  due  to  the 
same  paralyzed  condition  of  the  intestine,  whether  complete  or  in- 
complete, which  has  been  already  considered.  The  second  group 
embraces  those  infiltrations  which  result  from  inflammations,  and 
new  growths  of  different  kinds  which  lead  to  strictures. 

The  former  of  these  are  recognized,  as  far  as  they  can  be  with 
certainty,  by  the  history  of  the  case.  The  latter  present  peculi- 
arities in  the  form  and  size  of  the  faeces,  distention  of  the  bowels 
above  the  seat  of  the  narrowing,  vomiting,  attacks  of  colic, 
gradual  wasting  and  exhaustion ;  besides  which,  extreme  costive- 
ness,  deepening  gradually  into  invincible  constipation,  furnishes  a 
key  to  the  grievous  nature  of  the  affection. 

When  the  constipation  arises  as  the  result  of  peritoneal  adhe- 
sions, there  are  sometimes  signs  in  the  case — such  as  tenderness 
at  a  particular  spot  from  still  existing  inflammation,  or  j)artial 
distention  or  retraction  of  the  abdomen — which  point  out  its 
nature.  In  the  absence  of  these,  the  history  is  our  only  guide, 
except  in  those  instances  in  which,  as  Bright*  first  informed  us, 
a  peculiar  sensation  is  communicated  to  the  touch,  varying  between 
the  crepitation  produced  by  emphysema  and  the  feel  derived  from 
bending  new  leather  in  the  hand. 

Disorders  in  which  Morbid  Discliarges  from  tlie  Bowels  occur. 

Matters  very  unlike  the  healthy  alvine  evacuations  are  often 
voided  from  the  intestinal  canal :  loose  watery  stools,  large  quan- 
tities of  mucus,  pus,  or  blood,  may  be  discharged.  The  disorders 
which  occasion  these  discharges  may  be  here  described. 

*  Cases  illustrative  of  the  Diagnosis  of  Adhesions  and  other  Morhid  Changes 
of  the  Peritoneum,  Med.-Chir.  Transact., vol.  xix. 


576  MEDICAL    DIAGNOSIS. 

Diarrhoea. — Like  constipation,  (liari-ho?a  occurs  as  an  accom- 
paniment to  a  vast  number  of  diseases  which  present  symptoms 
more  characteristic  than  the  confined  or  loose  state  of  the  bowels. 
At  this  place,  diarrh(va  will  be  merely  treated  of  as  we  meet  with 
it  constituting-  the  entire  ailment,  or  at  all  events  its  most  promi- 
nent symptom.  There  are  several  varieties  of  diarrhoea.  Diifer- 
ence  in  time  gives  rise  to  marked  varieties, — to  an  acute  and  to  a 
chronic  form ;  and  it  has  of  both  already  been  pointed  out  how 
often  the  lesion  is  an  intestinal  catarrli. 

Acute  Diarrhcea. — Acute  diarrhoea  proceeds  from  more  than 
one  cause  :  it  may  be  excited  by  the  irritating  character  of  the 
food  taken,  or  by  impure  water;  it  may  be  brought  about  by 
the  morbid  nature  of  the  secretions  i)oured  into  the  intestines  ; 
it  may  be  owing  to  atmospheric  influences, — to  heat,  to  moisture, 
to  contaminated  air ;  it  may  be  caused  by  chilling  of  the  surface 
of  the  body,  or  by  irritant  poisons,  retained  fseces,  or  worms. 
It  may  be  occasioned  by  pyremia  and  septicremia,  by  reflex  irrita- 
tion, as  in  dentition,  or  by  mental  emotions,  and  especially  by  fear. 
Sometimes  it  occurs  in  an  epidemic  form  due  to  some  unknown 
miasm.  Its  symptoms  are  thirst ;  abdominal  uneasiness ;  grij^ing 
pain  in  the  bowel ;  pallor ;  slight  debility ;  and  frequent  fluid 
alvine  evacuations,  which  may  finally  become  almost  colorless. 

In  the  diarrhoea  caused  by  a  debauch  or  by  indigestible  food, 
nausea  and  a  furred  tongue  are  added  to  the  list  of  symptoms 
mentioned.  This  kind  of  diarrhoea  is  generally  of  short  dura- 
tion. It  is  an  eifort  of  nature  to  get  rid  of  obnoxious  matter ; 
and  when  this  is  effected,  the  looseness  of  the  bowels  ceases. 

The  variety  of  diarrhoea  under  consideration  sometimes  goes 
hand  in  hand  with  a  disturbance  of  the  biliary  functions,  and  the 
stools  discharged  are  fetid,  and  present  the  appearance  genei'ally 
described  as  bilious.  This  "bilious  diarrhoea,"  too,  is  not  un- 
common in  persons  whose  livers  are  habitually  sluggish.  It  is 
also  frequently  encountered  during  the  hot  months  of  summer 
and  early  in  the  autumn,  and  has  a  tendency  to  run  on. 

There  are  cases  of  diarrhoea  attended  with  jmin,  considerable 
soreness  to  the  touch,  and,  what  is  not  ordinarily  met  with  in 
diarrhcea,  some  febrile  disturbance.  These  kinds  of  acute  diar- 
rhoea, or  rather  of  acute  intestinal  catarrh  or  of  muco-enteritis  with 
diarrhoea  as  a  symptom,  are  often  the  result  of  irritant  poison- 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         577 

ing,  or  are  common  as  tlie  result  of  tlic  influence  of  cold,  or  of 
acrid  drinks  and  unripe  fruit.  They  are  also  observed  as  sec- 
ondary disorders  in  typhoid  fever  and  in  the  exanthemata. 

Chronic  Diai-rhcea. — In  chronic  diarrhoea  the  lesions  encoun- 
tered are  much  more  marked  than  they  ever  are  in  the  acute  form. 
The  mucous  membrane  is  tumid  and  discolored ;  its  follicles  are 
not  unfrequently  ulcerated.  Chronic  looseness  of  the  bowels 
originates  in  a  diarrhoea  which  is  permitted  to  continue,  either 
from  neglect  or  because  the  patient  remains  for  a  long  time  ex- 
posed to  the  original  cause.  But  the  disorder,  no  matter  under 
what  circumstances  it  originated,  is  apt  to  prove  rebellious,  and 
to  end  by  breaking  down  the  constitution.  When  of  long  stand- 
ing, the  patient  becomes  gradually  weaker  and  weaker,  and  more 
and  more  emaciated.  The  abdomen  is  sunken  ;  the  expression  of 
the  face  despondent ;  the  complexion  pale;  the  eyes  are  surrounded 
by  a  dark  ring.  The  character  of  the  discharges  is  very  various. 
They  are  often  dark-colored  and  very  offensive.  Sometimes  the 
looseness  of  the  bowels  alternates  with  an  opposite  condition ;  but 
the  irritability  of  the  intestines  never  intermits. 

This  morbid  excitability  of  the  intestinal  tube  is  especially 
brought  about  in  persons  of  nervous  temperament  and  of  dis- 
sipated habits.  The  abuse  of  purgatives,  too,  induces  it,  and  in 
consequence  chronic  diarrhoea  is  not  an  uncommon  result  of  the 
cathartic  pills  which  many  of  the  patrons  of  quack  medicines 
habitually  swallow. 

But  perhaps  the  most  persistent  irritability  of  the  intestines  is 
found  in  the  diarrhoea  to  which  soldiers  are  so  liable,  and  which 
is  apt  to  pass,  no  matter  what  its  beginning,  into  the  chronic  form 
of  the  disease.  And  this  complaint,  which  is  generally  associated 
with  a  morbid  state  of  the  large  intestine  as  well  as  of  the  small, 
which  combines  therefore  some  of  the  features  of  chronic  dysentery 
with  those  of  chronic  diarrhoea,  is  one  that  often  clings  to  its  victim 
through  life :  many  a  soldier,  in  truth,  escapes  the  bullet  and  the 
sword,  only  to  die  of  the  intestinal  affection  long  after  his  return 
to  his  home. 

The  causes  of  the  diarrhoea  in  soldiers  are  the  ordinary  causes  of 
chronic  diarrhoea  already  mentioned,  favored  in  their  development 
by  fatiguing  marches,  by  want  of  personal  cleanliness,  by  defec- 
tive diet,  by  the  exposure  in  camp,  by  hot  weather,  by  malaria, 

37 


578  MEDICAL    DIAGNOSIS. 

and  in  many  instances  by  a  sptvific  c[)idcmic  poison  in  the  atmos- 
phere* and  by  scurvy.f  The  chronic  diarrliaai  among-  s;oldiers  is 
not  materially  ditt'erent  in  its  symptoms  from  chronic  diarrho-a 
of  civil  life,  except  that  pcrhajis  -sve  find  more  fre<|uently  thielcen- 
iug  and  nlceration  of  the  colon  ;  more  frequently,  therefore,  stools 
containing  pus,  and  more  of  the  evidences  of  chronic  dysentery 
than  usually  coexist  with  what  is  known  as  chronic  diarrhoea. 
Then,  the  affection  is  very  often  witnessed  as  a  complication  of 
other  disorders.  Two-thirds  of  the  fever  patients  received  in  the 
hospitals  at  Constantinople  during  a  long  period  of  the  Crimean 
"War  were  affected  with  diarrhoea  or  with  dysentery.  Diarrhoea 
was  so  very  general  that  nearly  all  disorders  were  preceded  by 
acute  diarrhoea  and  terminated  in  chronic  diarrhoea.^  It  was 
much  the  same  in  this  country  during  General  INIcClellan's  penin- 
sular campaign. 

But  chronic  diarrhoea,  as  the  practitioner  of  medicine  commonly 
sees  it,  is  not  always  so  strictly  an  idiopathic  ailment  as  are  for 
the  most  part  the  forms  of  the  malady  just  discussed.  It  is  often 
attendant  on  general  constitutional  affections,  or  on  abdominal 
diseases  which  have  led  to  a  secondary  disorder  of  the  secretions, 
or  even  of  the  coats  of  the  intestine.  Thus,  we  find  chronic  loose- 
ness of  the  bowels  in  scurvy,  in  pyEemia,  in  Bright's  disease,  in 
scrofula  of  the  mesenteric  glands,  and  in  tuberculosis.  In  tlie 
last  of  these  complaints  the  diarrhoea  may  be  occasioned  by 
changes  in  the  secretions  of  the  intestinal  glands ;  but  it  is  not 
seldom  dependent  upon  a  true  tubercular  disease  of  the  intestines, 
which,  like  the  disease  of  the  lung,  leads  to  softening  and  ulcer- 
ation. The  discharges  are  generally  coi)ious  and  very  offensive. 
They  show  traces  of  blood,  and  contain  frequently  undigested  food. 
The  diarrhoea  is  continuous  and  intractable ;  the  abdomen  is  re- 
tracted, and  presents  spots  very  tender  to  the  touch.  There  are 
marked  fever  and  emaciation,  and  there  may  be  severe  intestinal 
hemorrhage.     Yet,  after  all,  onlv  the  signs  of  tubercle  elsewhere 


*  Blue  Book,  Medical  and  Surgical  History  of  the  War  against  Eussia, 
vol.  ii.  p.  101. 

f  Woodward,  Outlines  of  the  Chief  Camp  Diseases,  p.  2i")B  ;  see  also  the 
elaborate  analysis  of  the  alvine  fluxes  in  vol.  ii.  of  the  splendid  "  Medical  and 
Surgical  History  of  the  War  of  the  Rebellion,"  Washington,  1879. 

X  Baudens,  La  Guerre  de  Crimee. 


DISEASES    OF   THE    INTESTINES    AND    PERITONEUM.         579 

furnish  any  positive  indications  by  which  the  true  nature  of  the 
wasting  malady  can  be  discerned.  Indeed,  it  may  happen  that 
the  reverse  of  diarrhoea  occurs,  for  acute  primary  miliary  tuber- 
culosis may  simulate  an  acute  intestinal  obstruction.* 

In  the  chronic  diarrhosa  of  strumous  children  there  is  sometimes 
a  scrofulous  infiltration  into  the  intestinal  walls,  sometimes  marked 
scrofulous  enlargement  of  the  mesenteric  glands,  sometimes  both, 
but  in  some  cases  neither.  Improper  nourishment,  however,  may 
be  here,  as  in  any  other  form  of  the  diarrhoea  of  childhood,  the 
exciting  cause  of  the  continued  purging. 

At  times  chronic  diarrhoea  assumes  an  intermittent  type,  and 
its  malarial  nature  is  clearly  proved  by  the  readiness  with  which 
the  disorder  yields  to  quinine.f  In  this  respect  malarial  diar- 
rhoea differs  from  cases  of  diarrhoea  we  sometimes  encounter,  in 
which  the  pain  and  discharges  come  on  at  an  early  hour  of  the 
day  and  cease  toward  evening  and  during  the  night. 

Another  form  of  looseness  of  the  bowels  is  the  membranous. 
Here  the  discharges  show  shreds  of  membrane,  either  in  con- 
nection with  the  loose  stools,  or  sometimes  in  such  quantities  that 
the  whole  mass  voided  seems  to  consist  of  them.  Griping  pains 
and  tenderness  usually  precede  this  kind  of  diarrhoea,  w^iich  may 
happen  in  attacks  of  a  subacute  form,  or  as  a  persistent  and  very 
obstinate  disorder :  the  former  variety  is  the  more  common.  The 
fsecal  discharges  are  loose,  but  occasionally  for  a  time  there  is 
constipation.  The  disease  is  often  associated  with  peculiar  hys- 
terical symptoms.  The  so-called  membranes,  in  this  membranous 
enteritis,  contain  a  large  amount  of  mucus,  as  I  have  elsewhere 
described.^ 

Dysentery. — Frequent  and  painful  passages  of  mucus  mixed 
with  blood,  accompanied  by  straining  and  bearing  down,  are  the 
characteristic  symptoms  of  dysentery.  In  the  acute  form  we  find 
thirst,  restlessness,  and  heat  of  skin  superadded ;  and  sometimes, 
especially  when  the  disease  prevails  epidemically,  those  symptoms 
of  prostration  which  are  commonly  designated  as  typhoid. 

Acute  Dysentery. — The  acute  disorder  is  at  times  ushered  in  by 

*  Thoman,  AUg.  Wien.  Med.  Zeit.,  1887. 

t  See  contribution  by  Sanford  B.  Hunt  on  Diarrhcea,  in  Medical  Memoirs 
of  U.  S.  Sanitary  Commission,  p.  306. 

X  American  Journal  of  the  Medical  Sciences,  Oct.  1871. 


580  MEDICAL   DIAGNOSIS. 

a  chill ;  at  times  it  is  preceded  by  diaiTha?a.  The  fever  which 
attends  it  is  not  generally  intense.  It  is  the  exception  to  find  a 
hard,  rapid  pnlse,  and  a  very  hot,  dry  skin ;  and  in  light  cases 
the  pnlse  is  bnt  little  excited,  and  the  temperature  only  slightly 
raised.  More  or  less  pain  is  always  present.  It  has  its  seat 
mostly  at  some  part  of  the  colon,  and  this  is  tender  on  jiressure. 
It  is  intermitting  and  shifting,  and  is  often  accompanied  by  a  I'eel- 
ing  of  weight  near  the  anus,  which  causes  a  continual  desire  to  go 
to  stool.  Yet  no  relief  follows  the  frequent  attempts ;  the  violent 
straining  only  adds  to  the  discomfort. 

The  matters  voided  are  small  in  quantity.  They  consist  of 
blood  mixed  with  mucus ;  but  they  are  composed  not  simply  of 
mucus,  but  also  of  pus-corpuscles,  exudation  globules,  granules, 
and  large  quantities  of  cast-off  epithelium.  They  are  in  some 
cases  highly  offensive,  and  resemble  the  washings  of  meat;  in 
others  they  are  like  jelly,  or  greenish  in  color.  They  do  not  con- 
tain faeces,  or  only  here  and  there  small,  firm  lumps  of  ftecal  matter: 
hence  we  may  justly  say  that,  for  the  most  part,  dysentery  is  in 
reality  attended  with  constipation.  When  the  dysenteric  inflam- 
mation subsides,  the  bowels  are  unloaded  of  their  contents ;  in 
consequence,  the  passage  of  quantities  of  small,  hard  masses  of 
faeces  is  generally  a  sign  that  the  acute  malady  is  inclining  to  a 
favorable  termination.  Sometimes  the  stools  are  very  dark  and 
slimy  and  have  a  putrid  odor,  and  here  and  there  pieces  of 
sloughed-off  tissue  can  be  detected.  This  kind  of  stool  marks 
the  diphtheritic  or  gangrenous  variety  of  the  malady, — though  it 
is  not  constant  even  in  this, — and  is  apt  to  be  associated  with 
vomiting,  with  hiccough,  and  with  great  depression. 

How  long  it  will  take  for  the  disorder  to  run  its  course,  or 
whether  the  acute  disease  will  pass  into  chronic  dysentery,  cannot 
be  foretold.  Generally  this  is  not  its  termination  ;  it  very  often 
ends,  within  a  week  from  its  beginning,  in  recovery.  But  severe 
eases  occur  which  are  of  much  shorter  duration,  and  in  which  the 
symptoms  hasten  on  to  complete  prostration,  and  death  takes  place 
early  in  the  malady.  In  these  frightful  cases — most  frequently 
encountered  in  epidemics — collapse  may  happen  with  almost  the 
same  rapidity  as  it  does  in  malignant  cholera. 

Dysentery  is  essentially  a  disease  of  hot  climates.  It  is  very 
common  in  this  country  in  summer  and  in  autumn.    Eating  green 


DISEASES   OF   THE   INTESTINES   AND   PERITONEUM.        581 

fruits,  exposure  to  a  chilly  night  after  a  hot  day,  and  sleeping 
on  damp  ground,  are  prolific  exciting  causes.  It  is  occasionally 
found  in  combination  with  malarial  fevers,  adding  greatly  to 
their  danger,  or  with  scurvy.  The  immediate  cause  of  most  of 
the  symptoms  is  the  inflammation  of  the  large  intestine,  and 
especially  of  the  portion  which  commonly  bears  the  brunt  of  the 
disorder, — the  descending  colon.  Yet  in  many  cases  of  dysentery 
we  see  phenomena  manifested  which  are  clearly  not  to  be  accounted 
for  solely  by  the  local  morbid  appearances  detected  after  death, 
and  which  show  that  dysentery  is  often  something  more  than 
mere  inflammation  of  the  colon,  and  belongs  to  the  infectious 
maladies.  In  truth,  inflammation  of  the  colon  may  give  rise 
to  the  symptoms  of  acute  diarrho3a;  for  it  is  a  great  mistake  to 
suppose  that  the  cause  of  diarrhoea  is  only  to  be  sought  in 
some  abnormal  change  in  the  small  intestines.  Thus,  colitis  is 
not  always  dysentery ;  and  dysentery  is  often  more  than  mere 
colitis. 

But  whether  dysentery  is  simply  inflammation  of  the  colon ; 
or  an  inflammation  of  the  colon  arising  from  a  diseased  state 
of  the  blood,  and  forming,  therefore,  only  part  of  a  general 
malady ;  or  sometimes  one,  sometimes  the  other, —  we  find  that 
it  presents  peculiarities  which  render  it  easy  of  recognition  at 
the  bedside. 

Yet  we  must  take  good  care  to  ascertain  that  the  supposed  char- 
acteristic tenesmus  and  bloody  discharges  are  not  really  owing  to 
piles,  or  to  morbid,  especially  cancerous,  growths  in  the  rectum,  or 
to  its  ordinary  limited  inflammation.  In  the  latter  case,  or  j^roc- 
titis,  there  is  much  pain  when  the  hardened  faeces  are  discharged,  the 
rectum  is  forced  down  during  the  efforts,  the  sphincter  contracts 
spasmodically.  Strangury  and  hemorrhoids  are  not  uncommon 
symptoms ;  and,  as  the  consequence  of  the  inflammation  extend- 
ing to  the  parts  around  the  anus,  an  abscess  may  follow. 

There  is  less  danger  of  confounding  enteritis  or  diarrhoea  with 
dysentery,  for  symptoms  exist  in  the  latter  which  do  not  belong 
to  either  of  the  former.  Enteritis  has  fever ;  so  has  dysentery, 
though  the  febrile  disturbance  is  not  often  of  a  high  grade.  And, 
independently  of  the  differences  arising  from  the  absence  of  the 
peculiar  discharges  of  dysentery,  the  pulse  of  enteritis  is  small, 
tense,  and    quick  ;    that   of  dysentery,  if  the   febrile   action  be 


582  MEDICAL    DIAGNOSIS. 

niarktxl,  full  and  ra])i(l.  Diarrluva  differs  from  dysentery  by  the 
liqnid  txc-ixl  cvaeuations,  and  by  the  fact  that  neither  tenesmus, 
nor  bloody  stools,  nor  discharges  of  mucus  occur.  Yet  in  practice 
we  meet  with  eases  which  commence  with  diarrhoea  and  end  with 
dysentery,  or  begin  with  dysenteric  symptoms  and  terminate  in 
diarrhoea,  and  in  which  it  becomes,  therefore,  puzzling  to  say 
which  disorder  we  arc  dealing  with. 

Chronic  Dysentery. — In  chronic  dysentery  this  mingling  of  the 
two  complaints  is  especially  apt  to  happen.  We  rarely  see  chronic 
dysentery  without  chronic  diarrhoea.  At  all  events,  we  seldom 
find  instances  of  the  former  in  which  the  tenesmus  and  the  dis- 
charge of  blood  and  mucus  mixed  ^vitll  pus  are  not  accompanied 
by  frequent  loose  alvinc  evacuations,  by  griping,  by  the  same 
gradual  wastiug  and  the  same  irritability  of  the  bowels  as  are 
encountered  in  chronic  diarrhoea;  nay,  the  symptoms  of  the  latter, 
and  the  difficulty  of  determining  the  presence  of  pus  when  mixed 
with  fluid  faeces,  may  so  obscure  the  true  nature  of  the  malady 
that  what  has  been  regarded  as  chronic  diarrhoea  turns  out,  at  the 
autopsy,  to  be  chronic  dysentery.  The  mucous  membrane  of  the 
colon  is  found  to  be  extensively  inflamed ;  its  texture  altered  and 
irregularly  thickened ;  its  surface  riddled  Mith  ulcers.  In  such 
cases  the  patient  goes  on  steadily  losing  flesh,  has  some  elevation 
of  temperature ;  but  no  pain  on  pressure  or  localized  distress  ex- 
ists to  denote  the  ravages  the  disease  is  making  in  the  alimentary 
tube. 

The  prognosis  is  never  very  favorable.  To  say,  indeed,  that  it 
is  wholly  unfavorable,  would  hardly  be  to  overi-ate  the  serious 
character  of  the  disease.  Many  die  from  exhaustion ;  others,  in 
consequence  of  abscess  of  the  liver,  which  chronic  as  well  as 
acute  dysentery  may  induce. 

Intestinal  Hemorrhage,  or  Melsena. — This  is  commonly 
the  result  of  a  mechanical  hinderance  to  the  flow  of  blood  through 
the  liver,  as  in  cirrhosis,  or  of  disease  of  the  heart,  or  of  a  depraved 
state  of  the  circulating  fluid, — such  as  exists  in  typhus  fever,  in 
yellow  fever,  in  scurvy,  or  in  jDurpura.  Occasionally  the  bleeding 
proceeds  from  a  fungoid  growth  in  the  intestine,  or  from  aa  ulcer 
in  the  duodenum  or  ileum,  or  from  an  invagination,  or  from  fsecal 
impaction,  or  from  amyloid  degeneration  of  the  mucous  membrane 
of  tlie  bowel,  or  is  due  to  a  disease  of  the  spleen,  or  to  the 


DISEASES   OF   THE    INTESTINES    AND    PERITONEUM.         583 

bursting  of  an  aneurism.  Rokitansky  informs  us  that  intestinal 
hemorrhages  sometimes  follow  extensive  burns  of  the  aljclominal 
parietes.  And  in  very  young  infants  a  discharge  of  blood,  both 
by  the  mouth  and  by  the  rectum,  is  not  unusual. 

The  blood  passed  by  stool  is  generally  of  dark  colov,  like  tar. 
When  it  is  not,  we  may  fairly  infer  that  it  flows  from  the  lower 
part  of  the  intestine  and  has  not  had  much  chance  to  become  ad- 
mixed with  other  matters.  In  all  such  cases,  however,  we  must 
make  sure,  before  arriving  at  any  conclusion  as  to  the  source  of 
the  bleeding,  that  it  does  not  proceed  from  hemorrhoids.  The 
exact  seat  of  the  hemorrhage  cannot  be  determined ;  nay,  blood 
may  be  evacuated  by  the  bowel  and  not  be  poured  out  at  all  from 
the  intestine,  but  from  the  stomach.  In  some  instances  the  blood 
accumulates  in  the  bowel,  and,  before  the  clots  moulded  to  its 
shape  are  discharged,  death  results.*  When  the  bleeding  pro- 
ceeds from  hemorrhoids  it  is  very  seldom  vicarious. f 

In  point  of  diagnosis  the  first  thing  to  determine  is,  that  what 
is  supposed  to  be  blood  is  really  blood.  Very  dark  bilious  stools, 
or  stools  blackened  by  iron,  may  mislead.  If  doubt  exist,  water 
should  be  poured  on  the  stool,  and,  when  blood  is  present,  a 
reddish  tinge  is  imparted  to  the  water ;  still  more  accurate  is  it 
to  examine  with  the  microscope  or  the  spectroscope. 

W^e  next  have  to  ascertain  the  disease  with  which  the  intestinal 
hemorrhage  is  associated ;  and  this  is  often  a  very  difficult  matter. 
We  must  lay  the  greatest  stress  on  the  history  of  the  case,  look 
for  the  complaints — of  which  most  have  been  above  mentioned — 
which  are  apt  to  give  rise  to  the  bleeding,  especially  investigating 
for  cirrhosis  of  the  liver ;  searching  for  intestinal  ulcers  in  con- 
nection with  typhoid  fever  or  tuberculosis,  or  associated  with  the 
signs  of  a  disorder  of  digestion  in  a  duodenal  affection  ;  or  exam- 
ining for  the  evidence  of  scurvy  in  the  gums  and  skin,  or  for 
purpura  with  its  characteristic  spots  and  other  symptoms,  or  for 
marked  splenic  enlargement,  the  result  of  chronic  malaria,  or 
perhaps  combined  with  bone  disease  or  syphilis  and  joined  to 
amyloid  degeneration  of  liver,  kidneys,  and  intestinal  walls,  and 
then  presenting  albuminous  urine  and  diarrhoea.     Embolism  of 

*See  observations  of  Cheyne,  Dublin  Hospital  Eeports,  vol.  i.,  and  of  Bel- 
combe,  Medical  Gazette,  vol.  iv. 
f  Lee  on  the  Kectum. 


584  MEDICAL    DIAGNOSIS. 

the  superior  mesenteric  artery  may  also  occasion  intestinal  hem- 
orrhage. But  unless  we  have  with  the  bloody  stools  marked 
abdominal  pains,  peritoneal  exudation,  and  obvious  causing  ele- 
ments of  embolism  or  signs  of  it  elsewhere,  the  diagnosis  is  most 
uncertain. 

Fatty  DiarrhCEa. — The  occurrence  of  cases  in  which  large 
quantities  of  fat,  mixed  or  pure,  are  voided  by  the  rectum,  is 
well  attested.  In  some  of  these  cases  oil  Avas  at  the  same  time 
passed  with  the  urine;  in  others  the  urinary  secretion  was  healthy; 
some  cases  ended  fatally,  others  in  recovery ;  some  were  found  to 
be  connected  with  a  disease  of  the  pancreas,  others  were  not;  in 
some  the  disorder  was  not  of  long  continuance,  Avhile  in  others 
it  lasted,  with  intervals,  for  years.  Thus  the  morbid  state  with 
which  fatty  diarrhoea  is  associated  is  far  from  being  always  the 
same. 

As  a  rule,  the  occurrence  of  fatty  stools  is  a  matter  of  serious 
concern.  The  recognition  of  the  malady  is  easy.  The  Avhite, 
fatty  masses,  or  the  oily  matter  which  collects  on  the  discharges, 
are  soluble  in  ether,  and  are  readily  proved  to  be  fat  by  the  micro- 
scope ;  they  burn,  too,  like  fat,  with  a  flame.  In  some  instances 
the  bowels  are  very  constipated,  and  lumps  of  hard  faces  are 
discharged  along  with  the  fatty  substance.  This  happened  in  a 
marked  example  of  the  disorder  that  came  under  my  observation. 
The  patient,  a  man  twenty-six  years  of  age,  passed  a  consider- 
able amount  of  fat  both  by  the  rectum  and  with  the  urine.  He 
suffered  much  from  digestive  disturbance,  from  constipation,  and 
from  weakness.  He  had  a  good  appetite,  but  a  dislike  to  fats 
of  any  kind.  In  his  case  there  was,  as  far  as  the  other  symptoms 
and  the  physical  signs  indicated,  no  tumor  in  the  region  of  the 
pancreas.  The  man's  condition  was  much  improved  by  the  ad- 
ministration of  cinchona  and  rhubarb  ;  but  whether  permanently 
or  not  I  cannot  say,  as  I  lost  sight  of  him. 

I  have  also  met  with  instances  of  fatty  diarrhoea  associated  with 
saccharine  diabetes  and  with  disease  of  the  pancreas.  In  ex- 
amining into  the  subject  of  fatty  stools  it  must  be  borne  in  mind 
that  the  clay-colored  stools  of  jaundice,  owing  to  the  absence  of 
the  emulsifying  properties  of  the  bile,  contain  considerable  fat, 
which  may  be  found  in  oil-drops  or  as  fine  needle-shaped  fat- 
crystals. 


DISEASES    OF   THE    INTESTINES    AND    PERITONEUM.         585 

Diseases  attended  with  Vomiting  and  Purging. 

There  is  a  group  of  diseases  in  which  vomiting  and  purging 
are  very  prominent  symptoms.  It  embraces  those  disorders  in 
which  the  intestine  and  the  stomach  are  equally  involved.  To  this 
group  belong  some  affections  which  have  already  been  considered, 
which  begin  in  one  viscus  and  then  spread  to  the  other.  But 
those  in  which  both  are  primarily  affected  still  remain  to  be 
described.  The  most  important  of  them  are  the  various  forms  of 
cholera.  Now,  there  are  several  very  different  complaints  classed 
together  under  the  head  of  cholera.  Let  us  proceed  to  consider 
them  one  by  one. 

Cholera  Infantum. — And  first,  of  the  so-called  cholera  of 
infants.  It  is  an  endemic  in  the  larger  cities  of  the  United  States 
during  the  hot  months,  and  one  fraught  with  danger  to  all  young 
children.  Hundreds  die  of  this  summer  complaint  every  year  in 
our  densely-populated  towns. 

It  begins  generally  with  diarrhoea.  Vomiting  soon  follows ; 
and  for  a  time  the  two  go  hand  in  hand ;  but,  unless  the  case  be 
of  very  short  duration,  the  spontaneous  vomiting  ceases,  or  at  all 
events  gives  way  to  occasional  exacerbations  of  irritability  of  the 
stomach,  while  the  looseness  of  the  bowels  remains,  or  even  aug- 
ments. The  discharges  are  colorless,  or  yellowish,  or  greenish. 
There  is  thirst ;  sometimes  fever.  The  abdomen  may  be  sunken 
or  swollen ;  and  it  may  be  tender.  Sometimes  the  disease  runs 
its  course  within  three  or  four  days ;  at  the  end  of  which  time 
the  child  dies,  worn  out  by  the  constant  vomiting  and  purging. 
More  generally  the  disorder  is  of  longer  duration ;  for  weeks  or 
for  months  it  continues,  the  diarrhoea  improving  and  then  re- 
turning with  redoubled  severity,  and  kept  up  or  increased  by  the 
irritation  of  teething.  The  irritability  of  the  intestinal  canal,  and 
the  utter  impossibility  of  retaining  enough  food  to  nourish  the 
wasting  body,  gradually  wear  out  the  system.  The  child  before 
death  is  wan  and  distressingly  emaciated  ;  sometimes  suppression 
of  urine,  or  restlessness,  plaintive  cries,  rolling  of  the  head,  stra- 
bismus, coma, — the  symptoms  of  acute  hydrocephalus, — precede 
the  fatal  termination. 

Such  is  a  sketch  of  grave  and  intractable  cases.  Yet  many 
cases  are  far  from  being  so  desperate.     Under  judicious  treatment 


586  MEDICAL   DIAGNOSIS. 

a  larcje  number  are  annually  saved.  Reeoverics  would  bear  a 
still  higher  proportion  to  the  deaths,  were  it  not  that  the  greatest 
siilferers'from  the  disease,  the  children  of  the  poor,  are  unable  to 
obtain  the  means  most  certain  to  restore  them  to  health, — change 
of  air.  Cooped  up  in  crowded  neighborhoods,  surrounded  on  all 
sides  by  filth  rapidly  decomposing  under  the  burning  rays  of  the 
sun,  they  are  compelled  to  breathe  the  hot,  noxious  atmosphere 
which  has  been  the  chief  agent  in  generating  the  complaint. 

The  exact  pathology  of  the  disease  is  unknown.  The  careful 
researches  of  Lewis  Smith  have  familiarized  us  with  the  fact  that 
inflammation  of  the  whole  of  the  gastro-intestinal  tract,  with  en- 
largement of  the  solitary  glands,  and  even  of  Peyer's  patches, 
is  common.  But  whether  the  lesions  are  the  cause  or  the  conse- 
quence of  the  disorder  is  not  settled.  The  diagnosis  is  as  clear  as 
the  pathology  is  doubtful.  The  recent  researches  of  Vaughan 
have  demonstrated  that  a  ptomaine  appearing  in  milk,  tyrotox- 
icon,  is  a  frequent  cause  of  cholera  infantum.  Temporary  diar- 
rhoeas in  children  occurring  in  hot  weather  could  alone  be  mistaken 
for  the  disorder.  But  the  fact  that  they  are  temporary,  not  fol- 
lowed by  vomiting,  and  not  associated  with  the  grave  symptoms 
of  approaching  collapse,  shows  us  the  difference. 

Cholera  Morbus. — Like  the  cholera  of  infants,  cholera  mor- 
bus is  a  disease  of  the  hot  season ;  yet  it  is  also  observed  at  other 
times  of  the  year.  But,  although  the  chief  predisposing  cause 
is  undoubtedly  heat,  there  is  generally  an  exciting  cause  which 
develops  the  disorder, — such  as  exposure,  checked  perspiration, 
drinking  large  quantities  of  ice-water,  or  imprudence  in  eating. 
The  attack  is  characterized  by  spasmodic  pains  in  the  abdo- 
men, by  cramps  in  the  legs,  by  rapid  loss  of  strength,  and  by 
repeated  vomiting  and  purging.  The  matter  ejected  both  from 
the  stomach  aud  from  the  intestines  is  liquid,  and  contains  a 
large  quantity  of  bile.  In  truth,  the  affection  is  in  reality  a 
cholera,  a  flow  of  bile,  which  its  more  formidable  namesake, 
Asiatic  cholera,  is  not.  Finkler  and  Prior  have  found  in  the 
stools  a  comma-bacillus  which  is  larger  and  thicker  than  the 
bacillus  of  Asiatic  cholera,  and  rapidly  liquefies  in  gelatin. 

Cholera  morbus  may  be  preceded  by  colicky  pains,  nausea,  and 
rumbling  in  the  intestines.  More  generally  it  comes  on  suddenly, 
When  at  its  height,  the  cramps  in  the  calves  of  the  legs  cause  the 


DISEASES   OF   THE   INTESTINES   AND    PERITONEUM.        587 

muscles  to  rise  up  in  hard,  knotty  masses  ;  the  stools  arc  fetid  ;  the 
vomiting  is  constant ;  the  thirst  is  great,  and  the  skin  is  cool  or 
cold.  But  the  patient  does  not  long  remain  in  this  condition. 
In  the  course  generally  of  a  few  hours,  or  at  the  utmost  of  a  day, 
the  symptoms  mitigate,  or  yield  entirely  to  treatment ;  and,  pale 
and  visibly  emaciated  though  he  be,  he  speedily  regains  his  pre- 
vious health.  Only  in  some  cases  the  disease  proves  intractable, 
and,  after  running  on  for  several  days,  passes  into  a  state  of  hope- 
less collapse. 

There  are  not  many  morbid  states  with  which  cholera  morbus 
is  likely  to  be  confounded.  It  may  be  mistaken,  as  we  shall  pres- 
ently see,  for  epidemic  cholera.  We  find  many  points  of  similarity 
between  it  and  irritant  poisoning,  and  some  between  it  and  acute 
gastritis.  But  there  are  also  strong  points  of  difference.  The 
vomiting  and  purging  produced  by  an  irritant  poison  do  not 
come  on  at  the  same  time :  the  vomiting  precedes  the  purging. 
The  pain  is  first  in  the  epigastrium,  thence  it  may  spread.  More- 
over, we  often  detect  signs  in  the  mouth  or  fauces  which  prove  the 
irritating  character  of  the  substance  swallowed.  The  vomiting  of 
acute  gastritis  is  accompanied  by  fever,  and  a  small,  tense  pulse ; 
whereas  the  skin  of  cholera  morbus  patients  is  commonly  cool, 
and  the  pulse  very  compressible  and  feeble. 

Cholera. — The  formidable  complaint  known  as  epidemic  chol- 
era, Asiatic  cholera,  malignant  cholera,  or  by  the  simple  name  of 
cholera,  has  some  striking  featm-es  of  resemblance  to  the  disorder 
just  considered.  It  shares  with  cholera  morbus  the  vomiting  and 
purging,  the  cramps,  the  sudden  depression ;  but  it  is  an  affection 
of  different  origin  and  of  much  more  serious  import,  and  presents 
symptoms  not  encountered  in  the  cholera  that  occurs  yearly  during 
the  hot  weather.  And  although,  on  account  of  the  gastric  and 
intestinal  disturbances  which  form  so  prominent  a  part  of  its 
manifestations,  it  is  here  described  among  the  disorders  of  the 
alimentary  tube,  I  am  doing  so  for  the  sake  of  clinical  conve- 
nience, and  contrary  to  sound  pathology ;  for  cholera  is  not  an 
affection  either  of  the  stomach  or  of  the  intestines ;  it  is  an  epi- 
demic constitutional  disorder  of  the  most  formidable  character, 
generated  by  a  poison  transmitted  to  us  from  the  East.  The 
poison  leads  to  a  casting  off  of  the  epithelium  of  the  mucous 
membrane  of  the  alimentary  tube ;   perhaps  to  changes  in  the 


588  MEDICAL   DIAG>;OSIS. 

membrane.  But  the  engorcjed  veins  all  over  the  body  ;  the  ready 
exosmose  of  the  watery  parts  of  the  blood;  the  frightfully-rapid 
prostration ;  the  sudden  blight  which  befalls  the  nervous  powers, 
— are  elements  which  are  even  more  characteristic,  and  which 
throw  more  light  on  the  nature  of  the  fearful  malady,  than  the 
comparatively  uncertain  and  far  from  uniform  appearances  of 
irritation  in  the  intestinal  canal. 

The  access  of  cholera  is  at  times  sudden  and  most  unexpected  ; 
the  patient,  previously  in  good  health,  is  stricken  down  without 
warning  by  the  force  of  the  poison.  More  generally  there  is  a 
premonitory  stage :  a  stage  of  languor,  low  spirits,  uneasiness, 
headache,  and  diarrhcea.  The  effects  of  the  morbific  matter  are 
indeed  visible  in  hundreds  of  individuals  who,  during  the  preva- 
lence of  cholera,  suflFer  from  these  premonitory  symptoms  Avithout 
any  of  greater  danger  arising.  Nay,  the  same  influences  which 
give  rise  to  a  choleraic  diarrhoea  in  healthy  persons  have  the  effect 
of  rendering  the  bowels  of  those  habitually  constipated  regular, 
and  sometimes  even  loose. 

When  the  malignant  disease  is  fairly  developed,  there  is  vomit- 
ing as  well  as  purging.  The  contents  of  the  stomach  and  intes- 
tines are  first  voided,  and  then  large  quantities  of  a  rather  turbid 
fluid  resembling  rice-water,  with  whitish  particles  like  rice  float- 
ing in  it.  They  are  the  epithelial  cells  of  the  alimentary  tube, 
which  have  been  thrown  off  from  the  mucous  membrane ;  and 
in  the  dejecta  we  find  the  comma-bacillus  discovered  by  Koch.* 
This  may  be  seen  by  examining  microscopically  the  bacilli  ob- 
tained from  a  small  amount  of  cholera  dejection  which  has  been 
mixed  with  an  equal  amount  of  alkaline  meat  broth  and  allowed 
to  stand  for  twelve  hours  in  an  open  glass.  The  cholera-bacilli 
develop  on  the  surface.  Or  a  drop  of  the  infected  broth  or  a 
particle  from  a  stool  may  be  dried  between  two  cover-glasses, 
passed  three  times  through  the  flame  of  a  Bunsen  burner,  and 
stained  with  fuchsin  or  with  methyl-blue.f 

Simultaneously  with  the  vomiting  and  purging,  or  very  shortly 
after,  come  on  severe  spasmodic  pains  in  the  abdomen  and  cramps 
of  the  muscles  of  the  belly  and  of  the  extremities.      AVith  all 


*  This  is,  however,  denied.     See  Cohnheim,  Lehrb.  d.  Allg.  Pathol.,  ii.  124. 
t  Schottelius,  quoted  by  Jaksch,  op.  cit.,  1887. 


DISEASES    OF   THE    INTESTINES    AND    PERITONEUM. 


589 


this  there  are  a  burning  sensation  in  the  epigastric  region  ;  an 
unquenchable  desire  for  cold  drinks;  a  cool  skin;  a  pulse  slightly 
more  frequent  than  normal ;  a  temperature  wliich  may  be  normal 
or  may  fall  to  about  95°,  and  which  often  shows  many  degrees 
of  difference  between  the  rectum  and  the  axilla ;  an  oppressed 
breathing  ;  and  a  rapidly-progressing  exhaustion.  The  case  now 
stands  on  the  verge  of  collapse.  Should  this  follow,  a  state  of 
things  is  witnessed  which,  once  seen,  remains  indelibly  engraved 
on  the  memory.    The  pulse  is  quick,  but  hardly  perceptible.    The 


Fro.  43. 


The  comma-bacillus  of  Koch,  from  culture  in  blood-serum.     Zeiss  I'j,  homo,  im.,  Oc.  4. 

discharges  cease,  and  so  do  often  the  cramps.  The  skin  is  cold, 
covered  with  a  clammy  sweat,  and  has  a  bluish  look.  The  nails 
and  the  lips  have  the  same  unnatural  appearance.  The  whole 
body  shrinks,  and  seems  at  times  almost  to  wither  visibly  even 
while  under  inspection.  The  countenance  assumes  the  aspect  of 
death ;  the  eyes  are  sunken  and  have  a  glassy  look.  The  tem- 
perature is  low;  it  may  fall  to  79°.  .  The  intellect  is  commonly 
clear ;  but,  when  the  patient  talks,  the  M^ords  fall  strangely  on  the 
ear.     It  seems  as  if  a  corpse  had  spoken,  and  the  voice  is  husky 


590  MEDICAL   DIAGNOSIS. 

and  faint.    The  tongue  and  the  expired  air  are  cold.    No  synij)tom, 
indeed,  has  struck  me  more  forcibly  than  the  icy  breath. 

But  the  symptoms  do  not  always  take  place  in  the  order  de- 
scribed, nor  are  they  all  uniformly  present.  The  vomiting  and 
purging  may  be  Avanting  from  the  onset,  and  so  too  may  the 
cramps.  Only  one  symptom  is  never  absent, — the  tendency  to 
earlv  sinking.  Sometimes  a  stage  of  perfect  collapse  is  reached 
witii  frightful  rapidity  :  instead,  as  is  commonly  the  case,  of  sev- 
eral hours  elapsing  before  complete  prostration  comes  on,  the  vital 
powers  are  at  once  laid  low  by  the  assault  of  the  dreadful  malady. 
AVhen  cholera  prevailed  in  Philadelphia  some  years  since,  I  at- 
tended a  woman  who  at  six  o'clock  in  the  morning  was  in  perfect 
health  and  who  in  a  little  more  than  half  an  hour  afterward  was 
lifeless.  There  was  neither  vomiting  nor  purging ;  nothing  but 
cramps,  stupor,  and  speedy  collapse.  Such  cases  are  not  uncom- 
mon in  the  home  of  cholera, — India.  Post-mortem  inspection 
shows  the  thin  rice-water  fluid  locked  up  in  the  alimentary  canal. 
Nature  may  have  made  an  effort  to  eliminate  the  poison ;  but  before 
she  completes  her  task,  life  is  palsied. 

In  those  cases  that  recover,  or  in  tliose  of  light  character,  chol- 
erine, the  vomiting  and  purging  gradually  subside,  the  skin  be- 
comes warm,  the  pulse  fuller,  the  urine — ^which,  while  the  disease 
was  at  its  height,  was  not  passed,  perhaps  not  secreted — is  again 
voided,  the  patient  falls  into  a  refreshing  sleep,  and,  the  symp- 
tom most  favorable  of  all,  bile  reappears  in  the  stools.  Even  in 
apparently  hopeless  cases  of  collapse  we  may  be  fortunate  enough 
to  AA^itness  these  favorable  changes.  But  where  the  prostration 
has  been  great,  the  reaction  is  apt  to  be  violent.  A  decided  fever 
of  low  type,  with  rapid  pulse  and  heat  of  skin,  and  attended  very 
often  by  alarming  cerebral  symptoms,  succeeds ;  and  the  urinary 
secretion,  even  if  it  had  been  restored,  becomes  again  very  scanty. 
Thus  the  period  of  reaction  brings  with  it  new  dangers,  and  of  a 
kind  which  are  sometimes  insurmountable.  And  this  low  form 
of  fever,  very  similar  to  typhoid,  though  readily  enough  distin- 
guished by  the  preceding  symptoms,  may  last  for  upwards  of  a 
week  before  death  takes  place  or  the  signs  of  danger  gradually 
vield.  Now,  this  cholera  typhoid  may  be  preceded  by  scanty 
urine  and  marked  uraemia,  but  it  may  also  exist  independently  of 
this  morbid  state,  though  probably  equally  due  to  the  blood  being 


DISEASES    OF   THE    INTESTINES    AND    PERITONEUM.         591 

loaded  with  broken-down  material.  In  cases  in  which  urtemia 
sets  in,  whether  it  be  followed  or  not  by  a  fever  of  low  type,  there 
is  at  first  but  little,  if  any,  heat  of  skin,  and  a  slow  pulse ;  the 
patient  is  wild,  restless,  or  drowsy ;  the  kidneys  act  very  imper- 
fectly, the  urine  is  greatly  deficient  in  urea,  and  usually  contains 
albumen.  These  are  very  dangerous  cases,  and  if  the  secretion  be 
seriously  retarded  for  more  than  twenty-four  hours  they  are  likely 
to  perish. 

In  any  case  of  cholera,  convalescence  is  apt  to  be  slow.  For 
weeks  or  months  irritability  of  the  intestinal  canal  remains ;  and 
I  have  met  with  instances  in  which  it  has  never  disappeared. 

It  would  be  needless  to  go  into  any  minute  description  of  the 
differences  between  cholera  and  other  affections :  its  features  are 
not  to  be  mistaken.  Cholera  morbus  is  the  only  disorder  which 
really  resembles  it.  The  dividing-line  is  drawn  by  the  absence 
of  bile  in  the  discharges,  the  rice-water  evacuations,  the  greater 
severity  and  more  rapid  progress  of  the  symptoms,  the  bluish 
color  of  the  surface  in  the  stage  of  collapse,  and  the  epidemic 
character  of  the  more  fatal  disease.  In  the  truly  epidemic  nature 
of  the  distemper,  in  the  presence  of  the  cholera-bacillus  in  the 
evacuations,  and  in  the  speedy  collapse,  which  shows  but  too 
plainly  that  some  highly  deleterious  matter  has  poisoned  the  sys- 
tem, lie,  even  in  doubtful  cases,  the  proofs  that  we  are  dealing 
with  malignant  cholera ;  for  sometimes  rice-water  discharges  occur 
in  bad  cases  of  cholera  morbus;  occasionally,  too,  this  disorder 
appears  to  be  epidemic ;  but  it  is  only  on  a  very  small  scale. 
To  speak  more  accurately,  it  is  an  endemic  on  a  large  scale.  We 
find  no  proofs  of  a  virulent  poison  wafted  about  in  the  atmos- 
phere, or  directly  conveyed  by  human  intercourse  and  traffic,  and 
so  noxious  as  to  smite  animals  as  well  as  man.  Certain  rare  cases 
of  irritant  poisoning,  especially  from  arsenic,  bear  some  resem- 
blance to  cholera,  although  generally  more  to  cholera  morbus. 
The  severe  vomiting  in  advance  of  the  purging,  the  usual  absence 
of  rice-water  stools,  the  presence  of  bloody  evacuations,  and  the 
traces  left  by  the  poison  in  the  mouth,  furnish  significant  features 
of  distinction. 

The  mortality  of  cholera  is  very  various.  In  many  epidemics 
one-half,  or  more  thaij  one-half,  die.  In  some  the  havoc  is  far 
less.     The  first  cases  that  occur  almost  invariably  perish ;  and. 


592  MEDICAL    DIAGNOSIS. 

taken  altogether,  the  malady  ranks  among  the  most  destructive 
to  life.  Its  e})idemie  visitations  are  what  the  plague  was  to  the 
Europeans  of  the  seventeenth  century,  and  what  yellow  fever  still 
is  to  the  inhabitants  of  this  continent.  It  is  at  least  as  dangerous; 
its  nature  is  as  hidden ;  its  management  is  as  unsatisfactory. 


SECTION   III. 


DISEASES   OF   THE   LIVER. 


We  have  already  inquired  into  the  clinical  methods  of  exam- 
ining the  liver  with  a  view  to  forming  a  judgment  of  its  physical 
characteristics.     Let  us  now  look  at  some  of  the  symptoms. 

Pain  is  one  of  these.  It  is  generally  dull,  and  radiates  from 
the  seat  of  the  liver  to  the  upper  portion  of  the  thorax,  to  the 
scapula,  to  the  shoulder,  and  to  the  umbilicus.  Commonly  it  is 
persistent  and  increased  by  strong  pressure ;  yet  the  exceptional 
cases  are  numerous.  As  happens  with  other  symptoms  of  disease 
of  the  liver,  with  vomiting,  wdth  jaundice,  it  may  be  noticed  that 
the  pain  is  sometimes  strangely  periodical,  suggesting  malaria,  but 
uninfluenced  by  quinine.* 

Digestive  troubles  are  usual  accompaniments  of  hepatic  affec- 
tions. They  are  of  all  grades,  from  mere  indigestion  to  the  signs 
announcing  chronic  gastritis. 

Disturbance  of  the  jwrtal  circulation  is  another  frequent  conse- 
quence of  disease  of  the  liver.  The  flow  of  blood  is  interfered 
with,  and  the  result  is  seen  in  the  occurrence  of  dropsy,  of  piles, 
of  partial  peritoneal  inflammation,  of  hemorrhages  from  the  en- 
gorged stomach  and  intestines,  and  of  enlargement  of  the  spleen 
and  of  the  veins  on  the  surface  of  the  abdomen. 

Jaundice. — The  most  significant  manifestation  of  hepatic  dis- 
order is  ianndice.  This  marked  sign  shows  itself  by  the  yellow 
tinge  imparted  to  the  skin  and  to  the  conjunctiva.  Yet  the  yel- 
lowness is  not  confined  to  these  structures :  it  may  be  found  in 

*  See  on  this  subject  a  paper  by  Cyr,  Arch.  Gen.  de  Med.,  May,  1883. 


DISEASES    OF   THE    LIVER.  593 

internal  organs.  Besides  the  peculiar  aspect  of  the  surface,  icterus 
is  usually  attended  with  depression  of  the  circulation ;  with  itch- 
ing of  the  skin;  with  high-colored  urine,  in  which  the  main  in- 
gredients of  bile  can  be  detected,  and  sometimes  small  quantities 
of  albumen,  or  hyaline  and  epithelial  casts  without  albumen  ; 
with  constipation,  the  faeces  passed  being  hard  and  knotty,  and 
often  of  bad  odor,  and  almost  devoid  of  color,  or  of  a  leaden  hue. 

Jaundice  is  due  to  the  presence  of  biliary  constituents  in  the 
blood;  but  as  yet  it  is  not  satisfactorily  solved  how  they  get  there. 
The  generally-received  opinion  is  that  the  bile,  in  consequence  of 
some  impediment  to  its  outward  passage,  is  reabsorbed  and  con- 
veyed into  the  circulation ;  and  this  is  certainly  true  in  a  large 
number  of  cases  of  jaundice.  Again,  it  is  held  that  the  liver  is 
at  fault  by  not  performing  its  function  and  clearing  the  blood  of 
the  ingredients  which  form  the  bile ;  these,  whether  they  be  bile- 
pigment,  or  the  biliary  acids,  or  cholesterin,*  accumulate  in  the 
blood  and  give  rise  to  the  characteristic  discoloration  of  jaundice. 
Now,  neither  of  these  theories  will  explain  all  cases  :  many  in- 
stances of  jaundice  are  at  once  interpreted  by  the  former  suppo- 
sition, but  in  others  it  does  not  suffice,  and  the  view  of  jaundice 
from  suppression  would  appear  more  probable.  Still  other  theo- 
ries have  been  advanced  to  account  for  some  obscure  forms  of 
jaundice ;  such  as  the  view  of  Frerichs,  that  the  metamorphosis 
of  the  colorless  bile- acids  which  enter  the  blood  and  are  there 
changed  into  urinary  pigment  is  arrested  by  the  action  of  some 
poison,  and  that  the  acids  are  converted  into  bile-pigment,  which, 
circulating  with  the  blood,  changes  the  hue  of  the  surface  and  of 
the  secretions.  Then  in  the  jaundice  from  reabsorption  it  has 
been  demonstrated  that  the  bile  may  get  into  the  blood  in  conse- 
quence of  altered  pressure  in  the  vessels.  Lower  pressure  in  the 
vessels  causes  the  bile  to  flow  into  them. 

The  diagnosis  of  jaundice  is  ea.sy.  The  only  morbid  states 
with  which  it  is  liable  to  be  confounded  are  the  slightly  yellowish 
hue  of  chlorosis,  or  of  some  cachectic  conditions  combined  with 
organic  visceral  disease,  and  the  yellow  appearance  of  the  con- 
junctiva which  is  natural  to  some  persons.    The  changed  color  of 


*  Austin  Flint,  Jr.,  Amer.  Journ.  Med.  Sci.,  Oct.  1862.     See  also  Krusen- 
stern,  Virchow's  Archiv,  Ixv. 

38 


594  MEDICAL   DIAGNOSIS. 

the  conntonant'C  tluo  to  chlorosis  is  told  by  its  association  with  a 
l)luish-white  or  pcarly-tintcd  eye,  and  with  pale  lips  and  tongue 
and  tiafisparent  ear.  The  absence  of  a  yellow  tint  from  the  con- 
junctiva is  of  equal  importance  in  discriminating-  from  jaundice 
the  yellowish  hue  of  cancer,  of  malaria,  of  lead  poisoning,  and 
of  granular  kidneys.  The  history  of  the  case  also  aids  us.  The 
yellow  look  of  the  eye  sometimes  found  in  health,  and  at  times 
dependent  on  subconjunctival  fat,  is  known  by  the  unequal  dis- 
tribution of  the  color  and  by  the  absence  of  a  yellow  hue  of  the 
complexion.  But  in  negroes — and  it  is  in  them  especially  that 
we  meet  with  the  discolored  conjunctiva — we  have  to  judge  by 
the  character  of  the  coloration  alone.  In  any  doubtful  case,  the 
chemical  tests  for  bile-pigment  in  the  urine  will  solve  the  doubt. 

When  once  jaundice  has  been  recognized,  the  difficulty  in  diag- 
nosis may  be  said  to  begin.  Of  the  many  distinct  sources  of 
icterus,  which  one  is  before  us?  Now,  clinically  speaking,  the 
causes  may  be  thus  grouped  :  1.  Diseases  of  the  liver.  2.  Dis- 
eases of  the  bile-ducts.  3.  Diseases  of  parts  remote  from  the 
liver,  or  general  diseases  leading  to  a  disorder  of  the  viscus. 
4.  Certain  poisons  acting  upon  the  blood.  In  the  first  two  of 
these  causes  there  is,  as  it  were,  a  mechanical  difficulty  impeding 
or  arresting  the  excretion  of  bile;  in  the  third  and  fourth, 
no  obvious  impediment  exists,  and  the  origin  of  the  jaundice  is 
usually  obscure.  Cases  belonging  to  the  third  group,  however, 
may  be  at  times  explained  on  the  supposition  of  a  derangement 
of  the  hepatic  circulation.  Let  us  look  at  some  of  the  peculiari- 
ties of  these  groups. 

'  1.  The  jaundice  connected  with  diseases  of  the  liver  is,  as  a 
rule,  recognized  by  its  association  with  changed  dimensions  of 
the  organ,  and  with  pain  or  other  palpable  signs  referred  to  the 
hepatic  region.  It  is  met  with  in  all  disorders  of  the  liver,  but 
does  not  exist  in  all  in  the  same  degree  of  intensity.  It  reaches 
a  high  development  and  is  combined  with  cephalic  symptoms  in 
acute  yellow  atrophy.  In  fatty  liver,  in  waxy  liver,  in  cancer,  in 
cirrhosis,  and  in  acute  hepatitis,  it  is  not  marked, -and  may  be, 
indeed,  absent :  in  truth,  it  can  hardly  be  looked  upon  as  belong- 
ing; to  the  first-mentioned  morbid  states. 

2.  Jaundice  arising  from  disease  of  the  larger  biliary  ducts,  such 
as  their  catarrhal  swelling;  or  in  consequence  of  their  obstruction 


DISEASES   OF   THE   LIVER.  595 

by  pressure  exercised  by  a  morbid  enlargement  of  adjacent  parts, 
as  of  the  pyloric  extremity  of  the  stomach  or  the  pancreas ;  or  by 
tumors,  aneurismal,  cancerous,  or  faecal,  closing  the  orifice  of  the 
duct ;  or  by  the  stoppage  of  the  ducts  by  inspissated  bile  or  a  biliary 
calculus,  or  by  hydatids  or  foreign  bodies  from  the  intestines, — is 
a  form  of  the  malady  in  which  the  icterus  is  commonly  intense.  It 
occasions  no  head  symptoms ;  and  when  these  are  absent  in  a  case 
of  very  deep  jaundice,  when,  further,  the  stools  are  completely  dis- 
colored, we  are  generally  correct  in  attributing  the  morbid  phenom- 
ena to  an  impediment  to  the  flow  of  bile  through  the  common 
bile-duct  or  the  hepatic  duct.  If  this  impediment  be  due  to  the 
impaction  of  a  gall-stone,  severe  colicky  pains  are  encountered  in 
addition  to  the  signs  just  mentioned. 

In  the  jaundice  due  to  reabsorption — precisely  the  form  of  jaun- 
dice, therefore,  that  happens  if  any  serious  obstacle  in  the  biliary 
passages  exist — the  biliary  acids  pass  into  the  blood,  and  thence 
into  the  urine.  But  this  is  not  a  certain  sign  of  obstructive  jaun- 
dice.    Traces  of  the  bile-acids  have  been  found  in  healthy  urine. 

3.  Illustrations  of  jaundice  following  some  local  lesion  of  other 
parts  of  the  body,  or  appearing  in  the  course  of  a  general  consti- 
tutional affection,  are  furnished  by  the  jaundice  which  happens  in 
some  cases  of  pneumonia,  or  which  is  encountered  in  remittent, 
in  typhus,  in  relapsing,  or  in  yellow  fever.  In  these  fevers  the 
yellow  hue  is  generally  found  to  be  connected  with  an  acute 
enlargement  and  with  structural  changes  in  the  organ ;  and  in 
the  latter  malady,  with  disordered  hepatic  circulation  and  a  fatty 
degeneration  of  the  secreting-cells. 

To  recognize  the  form  of  jaundice  under  discussion,  we  must 
examine  all  the  viscera  of  the  body  with  care,  laying  stress  upon 
the  history  of  the  case  and  the  phenomena  attending  the  jaundice. 
Otherwise,  too  much  importance  will  be  attached  to  this  symptom, 
and  the  disturbance  of  the  liver  regarded  as  forming  the  whole 
complaint,  when  it  is  but  a  small  part  of  it. 

4:  Poisons  acting  upon  the  blood  sometimes  give  rise  to  jaundice 
very  rapidly ;  for  instance,  the  jaundice  from  snake-bites  or  from 
pygemic  affection  is  apt  to  be  suddenly  developed  and  to  become 
quickly  intense.  In  the  history  of  the  accident  and  the  signs  of 
alteration  of  the  blood,  we  possess  the  means  of  distinguishing 
this  form  of  jaundice.     Certain  mineral  poisons,  such  as  phospho- 


596  MEDICAL   DIAGNOSIS. 

rus,  copper,  antimony,  come  into  the  same  category.  Chloroform 
and  ether,  too,  may  lead  to  abnormal  blood  changes  producing 
janndice.  The  urine  enables  us  to  a  certain  extent  to  tell  blood 
jaundice  from  jaundice  caused  by  liver  disorder,  AVe  find  haniio- 
globin  in  the  urine  or  get  from  its  luomatin  the  luomin  crystals 
of  Teichinann.  These  are  obtained  by  drying  urine  on  a  slide, 
adding  a  little  salt,  and  then  glacial  acetic  acid  under  the  cover- 
glass.  The  slide  is  heated  until  bubbles  rise,  and  on  cooling  the 
characteristic  blood-crystals  form.  If  these  or  hremoglobin  bo 
found,  there  is  a  strong  probability  of  the  jaundice  being  of  blood 
origin. 

Thus,  then,  we  can  bring,  clinically  speaking,  most  of  the 
varieties  of  jaundice  under  one  or  the  other  of  the  four  heads 
mentioned ;  and,  roughly  speaking,  they  come  really  under  two, — 
obstructive  jaundice,  Avhere  the  disorder  results  from  obstruction 
of  the  common  duct,  and  jaundice  without  such  obstruction.  But 
there  are  a  few  kinds  of  jaundice  which  it  is  far  from  easy  to 
classify  with  precision :  one  of  these  is  the  jaundice  from  mental 
emotion ;  the  other,  the  jaundice  of  newly-born  children. 

As  regards  the  former,  no  satisfactory  explanation  has  been 
given.  All  we  know  is,  that  violent  anger  or  fright  may  lead, 
within  a  very  brief  space  of  time,  to  the  development  of  jaundice, 
and  that  the  quickly-occurring  discoloration  is  not  dangerous,  or 
of  long  duration.  The  perverted  innerva.tion  caused  by  concus- 
sion of  the  brain  leads  to  a  similar  kind  of  jaundice. 

The  jaundice  of  newly-born  children — icterus  neonatorum — is 
ordinarily  a  mild  complaint,  which  appears  soon  after  birth,  and 
rarely  lasts  over  two  weeks.  The  yellow  hue  of  the  skin  is  often 
very  deep;  yet  the  child  does  not  suffer,  and  has  no  febrile  excite- 
ment. The  bowels  are  constipated,  but  the  stools  are  not  neces- 
sarily altered  in  their  color ;  nor  do  they  usually  present  the 
clayey  look  which  might  be  expected  from  the  aspect  of  the  skin 
and  of  the  conjunctiva.  "West  states  that  the  disorder  is  most 
frequently  observed  in  children  prematurely  born. 

The  prognosis  of  jaundice  depends  upon  its  cause.  In  general 
terms,  we  may  say  that  if  the  icterus  last  upwards  of  two  months 
it  is  always  a  matter  of  some  danger,  as  showing,  in  all  likeli- 
hood, an  organic  lesion  of  the  liver  or  of  the  biliary  passages.  If 
the  discoloration  of  the  skin  be  attended  with  cerebral  symptoms. 


DISEASES    OF    THE    LIVER. 


597 


the  patient's  state  is  precarious.  Icterus  accompanying  affections 
of  the  blood,  peritonitis,  or  pneumonia  is  an  unfavorable  sign ; 
so  is  a  very  dark  color  of  the  skin.  Indeed,  cases  of  "  green"  or 
^'  black"  jaundice  generally  prove  fatal. 

Before  examining  the  hepatic  maladies  according  to  their  clin- 
ical features,  let  us  look  at  their  pathological  classification  : 

Diseases  of  the  Liver. 


Diseases  of 
hepatic 
parenchy- 
ma. 


Diseases  of 
biliary 
passages. 


Diseases  of 
blood-ves- 
sels. 


Hypersemia., 


Inflammation   and  its  conse 
quences 


-J 


Atrophy 

Hypertrophy . 


Degeneration    and    new   for- 
mations  


r  Of  hepatic  artery  , 
Of  hepatic  vein. 
Of  portal  vein 


L 

Inflammation  of  gall-bladder 
and  gall-ducts 

Occlusion  of  biliary  pas- 
sages. 

Dilatation  of  gall-bladder. 

Morbid  growths. 

Foreign  bodies  ;  concretions, 
such  as  o-all-stones. 


Acute  congestion. 
Chronic  congestion. 
Acute  hepatitis. 
Chronic  hepatitis. 
Interstitial  inflammation ;  cir- 

I'hosis. 
Abscess. 
Softening. 
Syphilitic  hepatitis. 
Acute  or  yellow  atrophy. 
Simple  chronic  atrophy. 
Eed  atrophy. 
Partial. 
General. 
Fatty  liver. 
Waxy  liver. 
Pigment  liver. 
Cancer. 
Sarcoma. 

Lymphatic  growths. 
Gummata. 
Tubercle. 
Hydatids. 
Simple  cysts. 
Catarrhal. 
Exudative. 
Suppurative. 


f  Inflammation. 
1  Aneurism. 

f  Suppurative  inflammation. 
I  Coagulation  of  blood. 


598  IMEDICAL    DIAGNOSIS. 

Acute  Diseases  of  the  Liver  attended  generally  with  Slight 
Enlargement  of  the  Organ,  and  with  more  or  less,  though 
rai'ely  very  much.  Jaundice. 

Acute  Congestion. — This  arises  from  organic  disease  of  tlie 
heart,  I'ruiu  obstructed  portal  circulation,  from  irritating  food  and 
drink  and  disturbed  digestion,  or  from  malarial  poison  ;  sometimes 
it  is  caused  by  a  high  temperature,  by  a  blow  on  the  hepatic 
region,  by  arrest  of  the  menstrual  flow,  by  a  protracted  chill,  by 
violent  exercise,  or,  as  Frerichs  points  out,  by  injury  to  the  semi- 
lunar ganglia.  The  acute  congestion  is  characterized  by  pain  in 
the  right  shoulder  and  loin,  by  an  unpleasant  sensation  of  weight 
and  of  tension  in  the  right  hypochondrium,  increased  after  meals, 
and  by  nausea  and  vomiting.  At  the  same  time  tlie  action  of  the 
bowels  is  deranged,  being  generally  too  frequent ;  the  tongue  is 
coated ;  there  is  flatulency,  as  well  as  depression  of  spirits,  with 
loss  of  appetite  and  of  strength;  and  the  liver  is  enlarged.  But 
we  find  ordinarily  only  slight  jaundice,  and  no  fever.  Gradually 
these  signs  disappear ;  the  increased  hepatic  dulness,  however, 
remaining  for  some  time  after  the  gastric  and  intestinal  disturb- 
ances have  abated.  Not  unfrequently  the  acute  disorder  passes 
by  imperceptible  degrees  into  a  chronic  state. 

Acute  Hepatitis. — The  symptoms  of  this  affection  are  much 
the  same  as  those  of  acute  congestion,  except  that  we  observe 
greater  gastric  irritability,  a  more  embarrassed  respiration,  rise  of 
temperature,  dry  cough,  and  in  some  cases  enlargement  of  the 
spleen,  and  albumen  in  the  urine.  The  pain  is  dull,  and  associated 
with  a  feeling  of  tension  in  the  hypochondrium.  It  is  increased 
on  pressure,  yet  not  much  so,  unless  the  peritoneal  covering  of  the 
liver  be  involved.  Jaundice  is  not  generally  marked  ;  indeed,  at 
the  beginning  of  the  disease  it  is  often  absent.  Ascites,  vomiting 
of  blood,  and  brown  spots  on  the  skin  have  been  noticed.* 

Acute  hepatitis  is  common  in  hot  countries,  and  many  of  the 
cases  are  connected  with  dysentery.  It  may  end  in  resolution ; 
but  the  inflammation,  especially  in  persons  of  indolent  or  intem- 
perate habits,  often  terminates  in  suppuration,  and  pus  collects  in 
the  substance  of  the  liver.     The  occurrence  of  this,  the  tropical 

*  Jos.  Brown,  Phila.  Mod.  and  Surg.  Reporter,  June,  1873. 


DISEASES    OF   TPIE    LIVER,  599 

abscess,  as  Murchison*  calls  it,  is  indicated  by  recurring  rigors,  hy 
fever  of  a  remittent  type,  by  clammy  perspirations,  by  prostration 
and  loss  of  flesh.  Not  unfrequently,  too,  a  decided  fulness  of 
the  side  may  be  noticed,  and  occasionally  careful  palpation  detects 
deep-seated  fluctuation.  After  an  abscess  has  formed,  the  danger 
is  great ;  secondary  abscess  may  follow,  and  the  patient  is  apt  to 
perish  from  peritonitis,  or  from  blood-poisoning.  Yet  recovery 
may  take  place.  The  matter  may  be  discharged  through  the  ab- 
dominal walls,  or  burst  into  the  intestine,  or  find  its  way  through 
the  diaphragm  into  the  pleural  cavity,  to  be  discharged  through 
the  lung.  But,  as  the  phenomena  of  abscess  of  the  liver  follow- 
ing acute  inflammation — if  we  except  jaundice,  which  is  a  rare 
symptom — are  the  same  as  when  the  collection  of  pus  is  conse- 
quent upon  other  morbid  states,  we  shall  not  here  consider  what 
we  shall  presently  more  fully  discuss. 

Let  us  now  examine  the  maladies  with  which  acute  inflam- 
mation of  the  liver  may  be  confounded,  premising  that,  making 
allowance  for  the  febrile  phenomena  and  the  other  slight  signs  of 
diiference  just  indicated  between  hepatic  inflammation  and  hepatic 
congestion,  the  same  remarks  will  apply  to  the  distinction  between 
this  morbid  condition  and  the  affections  about  to  be  mentioned. 
The  complaints  resembling  acute  hepatitis  are  : 

Perihepatitis  : 

Inflammation  of  the  Portal  Veins  ; 

Pigment  Liver  ; 

Chronic  Hepatic  Diseases  with  Acute  Symptoms  ; 

Acute  Non-Hepatic  Diseases  with  Jaundice  ; 

Diaphragmatic  Pleurisy; 

Acute  Infectious  Jaundice  ; 

Inflammation  of  the  Biliary  Passages; 

Acute  Yellow  Atp^ophy. 

Perihepatitis. — Inflammation  of  the  serous  covering  of  the  liver, 
limited  to  this  covering,  or  spreading  perhaps  here  and  there  to 
the  most  superficial  portions  of  the  structure  of  the  gland,  is  not 
a  frequent  disease.  Unless  it  be  of  syphilitic  origin,  it  is  scarcely 
ever  a  primary  affection ;  it  is  generally  caused  by  the  extension 
of  inflammation  from  organs  adjacent  to  the  liver, — as  from  the 

*  Diseases  of  the  Liver,  2cl  edit.,  1877. 


600  MEDICAL   DIAGNOSIS. 

stomach,  intestines,  diaphiagni,  or  pleura, — and  may  therefore 
be  looked  upon  as  a  local  peritt)nitis  ;  or  it  is  an  attendant  upon 
disease  of  the  liver  itself.  In  the  latter  ease  it  presents  no  pe- 
culiar symptoms,  except  that  it  adds  tenderness  to  the  signs  of 
tiie  hepatic  malady  it  complicates.  Under  other  circumstances  it 
is  more  likely  to  be  confounded  with  acute  inflammation  of  the 
liver-texture.  Yet  the  ilar  greater  tenderness,  the  severe  pain  upon 
motion  or  deep  inspiration  and  its  marked  increase  avIhii  the 
patient  lies  on  either  side,  occasionally  a  grating  friction  sound, 
the  perfectly  normal  size  of  the  gland,  the  history  of  the  case  or 
evidences  of  a  disease  in  the  neighborhood  of  the  liver  that  is 
likely  to  have  caused  the  malady,  the  absence  of  jaundice,  and 
the  slight  fever,  distinguish  the  perihepatic  inflammation  from 
true  hepatitis. 

Infiammation  of  the  Portal  Vein^. — An  inflammation  of  the 
portal  veins,  terminating  in  suppuration,  is  very  liable  to  be  mis- 
taken for  acute  inflammation  of  the  liver.  Nor  are  there,  in  truth, 
any  positive  symptoms  by  which  we  can  discriminate  between  the 
two  maladies.  Still,  we  may  suspect  that  the  veins  are  the  seat 
of  inflammation,  rather  than  the  structure  of  the  liver,  if,  av ith 
the  signs  of  acute  and  painful  enlargement  of  the  organ,  we  find 
jaundice,  thin  and  copious  stools,  recurring  chills  and  profuse 
sweats,  emaciation,  increase  in  size  of  the  spleen,  without  any 
apparent  nuctuation  or  other  signs  of  an  hepatic  abscess;  if  there 
exist  pains  between  the  ensiform  cartilage  and  the  umbilicus,  or 
in  the  epigastrium  or  right  hypochondrium,  or  shooting  to  the 
lumbar  and  sacral  regions ;  if  following  these  symptoms  appear 
swelling  of  the  veins  of  the  abdominal  walls,  and  striking  evi- 
dences of  hectic  fever,  or  of  peritonitis ;  and  if  these  phenomena 
be  encountered  in  a  person  who,  on  account  of  a  previous  affection 
of  the  intestines  or  spleen,  or  of  any  other  organ  having  a  direct 
venous  connection  with  the  portal  circulation,  is  liable  to  disease 
of  the  portal  system.  Marked  enlargement  of  the  spleen  is  a 
constant  feature  of  impediment  in  the  portal  vein,  whether  from 
inflammation  or  from  thrombosis. 

Pigment  Liver. — In  accumulation  of  pigment  in  the  liver,  which 
is  most  common  as  the  result  of  a  deep  malarial  poisoning,  the  liver 
is  not  the  only  organ  implicated  in  the  morbid  process :  the  spleen 
is  commonly  afi^ected  ;  the  blood  becomes  watery,  its  corpuscles  are 


DISEASES    OF    THE    LIVER.  GOl 

broken  down,  and  it  contains  large  quantities  of  pigment;  and 
pigment  accumulates  in  the  kidneys  or  in  the  brain.  Now,  the 
effect  of  all  this  is  to  occasion  marked  symptoms,  besides  those 
referable  to  the  derangement  of  the  liver ;  for  it  is  not  unusual 
to  find  grave  cerebral  disturbance,  albuminuria,  hemorrhage  from 
the  intestines,  profuse  diarrhoea,  and  enlargement  of  the  spleen. 
Irrespective  of  these  manifestations,  we  must  note  the  singular  ash 
or  grayish-yellow  color  of  the  skin,  the  evident  angemia,  and 
the  great  amount  of  pigment  which  is  readily  detected  in  even  a 
few  drops  of  the  blood.  The  fever  that  accompanies  the  morbid 
condition  is  of  an  intermittent  type ;  the  pulse  is  not,  as  a  rule, 
much  accelerated,  and  the  jaundice  is  generally  slight.  In  India, 
pigmentary  degeneration  of  the  liver  tends  to  suppurative  hepa- 
titis.* When  we  contrast  the  phenomena  described  with  those 
of  acute  hepatitis,  we  see  at  once  the  difference.  The  fever, 
the  aspect  of  the  patient,  the  blood  full  of  dark  pigment  and  ma- 
larial corpuscles,  and  the  frequency  of  cerebral  symptoms,  are 
entirely  unlike. 

Clwonic  Hepatio  Diseases  with  Acute  Symptoms. — We  occasion- 
ally meet  with  patients  who  seem  to  be  laboring  under  an  acute 
affection  of  the  liver,  either  some  form  of  inflammation  of  the 
liver- structure  or  of  the  biliary  passages,  or  congestion  of  the 
liver,  but  in  whom  the  acute  symptoms  have  merely  supervened 
upon  a  chronic  complaint.  Such  cases  are  puzzling;  it  may  be 
indeed  impossible  to  arrive  immediately  at  their  solution,  and 
we  have  to  wait  until  the  acute  symptoms  subside.  Sometimes, 
however,  au  accurate  inquiry  into  the  history  of  the  affection  will 
lead  to  a  knowledge  of  the  real  condition.  Still,  far  from  always; 
for  the  malady  may  have  been  latent  and  have  scarcely  attracted 
the  patient's  attention.  In  hepatic  cancer  the  sudden  and  rapid 
development  of  the  malady  amid  the  signs  of  acute  congestion  is 
not  very  uncommon.  Occasionally  the  peculiar  physical  phenom- 
ena of  individual  hepatic  diseases,  such  as  the  nodular  tumors 
of  a  malignant  growth,  or  th«  fluctuation  of  a  hydatid  cyst,  will 
assist  materially  in  the  diagnosis. 

Acute  Non-Hepaiic  Diseases  with  Jaundice. — There  are  many 
acute  affections,  such  as  pneumonia,  pyeemia,  puerperal  fever,  and 

*  Aitken's  Practice  of  Medicine,  vol.  ii. 


602  MEDICAL    DIAGNOSIS. 

some  forms  of  poisonino;^  in  \\liic'li  jauiulic'e  may  coincide  with 
febrile  symptoms  and  excite  susj)icions  of  acnte  hepatitis.  But  the 
yellowness  of  the  Kkin  which  may  attend  the  non-hepatic  disorders 
mentioned  is  accoiiijianicd  by  symptoms  so  different  from  those 
connected  with  the  jaundice  of  acute  inflammation  of  the  liver, 
that  a  mistake  is  not  likely  to  arise  if  the  histt)r}-  of  the  case  be 
taken  into  account  and  other  viscera  besides  the  liver  be  explored. 
Diaphrcigiiudic  l^lcuri.si/. — The  manifestations  of  inflanuuation 
of  the  pleural  covering  of  the  diaphragm  are  in  several  respects 
similar  to  those  of  inflammation  of  the  liver.  We  find  in  this 
dangerous  complaint  pain  in  the  right  hypochondrium,  nausea 
and  vomiting,  dry  cough  and  embarrassed  respiration,  occasion- 
ally jaundice, — much  the  same  symptoms  which  we  observe  in 
hepatitis,  especially  if  the  serous  envelope  of  the  liver  be  at  the 
same  time  implicated.  But  the  pain  in  diaphragmatic  pleurisy  is 
far  greater,  more  suddenly  developed,  is  much  more  aggravated 
by  movements  and  by  full  inspiration,  and  is  always  evoked  by 
pressure.  The  diaphragm  on  one  side  is  immovable ;  the  hypo- 
chondriac region  is  retracted  ;  the  breathing  is  purely  costal  and 
short ;  the  diiBculty  in  breathing  amounts  to  orthopnoea;  the  body 
is  bent  forward.  We  often  encounter  hiccough,  great  anxiety, 
and  delirium,  sometimes  a  sardonic  grin  on  the  features,  and  the 
cough  comes  on  in  frequent  paroxysms;  and  although,  as  a  case 
recorded  by  Andral  *  proves,  there  may  be  jaundice,  yet  this  is  in 
reality  so  generally  wanting  as  scarcely  to  belong  to  the  symptoms 
of  diaphragmatic  pleurisy.  Then  in  this  complaint  we  may  find 
friction  sounds, — though  the  physical  signs  will  not  always  aid 
us,  being  often  uncertain,t  and  consisting  simply  in  enfeebled 
breathing,  with  perhaps  a  few  fine  moist  rales  at  the  lower  portion 
of  one  side  of  the  chest.  The  fever  with  these  imperfect  physical 
signs  may  be  slight  or  be  very  marked ;  it  is  generally  ushered  in 
by  a  chill.  There  is  generally,  in  addition  to  tlie  pain  along  the 
cartilages  of  the  false  ribs,  a  tender  spot  in  the  epigastrium,  on  a 
level  with  the  tenth  rib,  one  or  two  finger-breadths  from  the  linea 
alba.  There  are  shooting  pains  along  the  clavicle  and  in  the  tract 
of  the  superficial  cervical  plexus,  and  the  phrenic  nerve  of  the 


*  Clinique  Medicale,  tome  ii. 

f  Cases  by  Habershon,  Guy's  Hospital  Eeports,  1869. 


DISEASES    OF    THE    LIVER.  00'3 

affected  side,  pressed  on  in  the  neck,  is  very  sensitive.  The  ])ain 
on  pressure  is  generally  most  intense  along  the  costal  insertions 
of  the  diaphragm,  especially  of  the  tenth  rib ;  it  is  stated  that 
upward  pressure  affords  a  means  of  diagnosis,  as  it  relieves  the 
pleuritic  pain.*  The  difficulty  in  expectorating,  owing  to  the 
pain,  may  be  so  great  as  to  hasten  death. f 

Acute  Infectious  Jaundice. — This  malady,J  also  known  as  Weil's 
disease,  presents  many  symptoms  of  acute  hepatitis.  It  is  very 
doubtful,  however,  whether  it  is  an  affection  of  the  liver,  but  is 
not  rather  an  infectious  fever,  possibly  the  result  of  ptomaines. 
It  is  marked  by  jaundice,  swelling  of  the  spleen,  nephritis,  and 
marked  blood-alteration.  It  mostly  affects  vigorous  young  men 
in  hot  weather ;  butchers  are  especially  liable  to  it.  It  begins 
abruptly  with  headache,  dizziness,  and  decided  elevation  of  tem- 
perature. The  jaundice  is  moderate,  the  liver  slightly  swollen 
and  painful ;  there  is  great  weakness,  with  delirium  and  somno- 
lency. Besides  albumen  and  tube-casts,  the  urine  may  contain 
blood ;  both  bile-pigment  and  bile-acids  are  found  in  it.  There 
are  pains  in  the  limbs,  especially  in  the  calves ;  the  bowels  may 
be  loose  or  bound.  The  symptoms  abate  quickly  ;  from  the  sev- 
enth to  the  eighth  day  the  temperature  falls  gradually  to  normal. 
A  return  of  fever  after  a  period  of  its  absence  from  one  to  seven 
days  may  happen,  but  this  return  does  not  last  more  than  three 
to  six  days.  The  convalescence  is  extremely  slow.  The  disease 
resembles  relapsing  fever,  but  the  spirilla  have  not  been  found 
in  the  blood.  The  return  of  the  fever  makes  it  unlike  abortive 
typhoid  with  bilious  symptoms,  which  it  resembles.  Then,  it 
shows  no  eruption,  except  herpes  and  an  erythema,§  and  diarrhoea 
is  not  constant.  The  jaundice  and  the  increased  percussion-dulness 
are  unlike  the  features  of  acute  yellow  atrophy,  and  the  course  of 
the  fever  is  different.  || 

Inflammation  of  the  Biliary  Passages  ;  Acute  Yelloio  Atrophy. — 
Both  of  these  maladies  may  be  confounded  with  hepatitis.  But 
the  former,  although  presenting  more  jaundice  than  the  other 

*  British  Medical  Journal,  Aug.  1871. 

f  Frank  Donaldson,  Jr.,  Amer.  Journ.  Med.  Sci.,  April,  1885. 

J  Described  by  Weil,  Deutsches  Archiv  fiir  Klin.  Med.,  Bd.  xxxix. 

§  Fiedler,  Deutsches  Archiv  f.  Klin.  Med.,  Feb.  1888. 

(I  Fraenkel,  Deutsche  Med.  Wochenschr.,  Feb.  1889. 


G04  MEDICAL    DIAGNOSIS. 

maladies  of  tlic  o;roiip  now  inuloi"  discussion,  is  otherwise  so  sim- 
ilai-  that  it  will  he  deserihed  as  one  of  the  main  affections  of  this 
group  ;  and,  in  trutii,  in  temperate  climates  acute  affections  of  the 
liver  are  nu)Stly  catarrhal  jaundice,  and  if  designated  as  hepatitis 
this  is  mostly  erroneous.  Acute  yellow  atrophy  belongs  clinically 
to  diseases  characterized  by  decrease  in  size  of  the  liver ;  and  it  is 
thei'c  tiiat  we  shall  point  out  its  ditferenees  from  acute  liepatitis. 

Inflammation  of  the  Gall-Bladder  and  Gall-Ducts. — 

InHannnation,  when  it  attacks  the  biliary  passages,  is  most  apt  to 
affect  the  gall-bladder  and  the  ductus  choledochus.  Frequently 
the  morbid  process  is  propagated  from  the  stomach  or  intestines, 
and  nausea,  furred  tongue,  a  feeling  of  Aveight  in  tiie  epigastrium, 
feverishness,  and  diarrhoea,  occur  previous  to  the  discoloration  of 
the  fseccs,  to  the  jaundice,  to  the  increased  hepatic  dulness,  and  to 
the  slight  tenderness  on  pressure  in  the  right  hypochondrium ;  in 
other  Avords,  the  symptoms  of  gastric  or  gastro-intestinal  catarrh 
precede  those  of  "  icterus  catarrhalis," — by  far  the  most  common 
form  of  inflammation  of  the  gall-bladder,  for  suppurative  inflam- 
mation is  very  rare. 

Catarrhal  icterus  does  not  cause  any  great  enlargement  of  the 
liver,  and  the  swollen  organ  remains  smooth  on  palpation.  Nor 
is  the  tenderness  decided,  except  over  the  tumid  and  projecting 
gall-bladder.  The  jaundice,  at  first  slight,  becomes  after  a  few 
days,  as  the  bile-ducts  are  obstructed,  intense,  and  the  stools  are 
white  and  devoid  of  bile.  There  is  now  no  fever,  and  usually  a 
slow  pulse.  The  affection  is  the  most  common  cause  of  marked 
jaundice  in  young  persons;  when  found  in  the  middle-aged  or  in 
the  old  it  is  apt  to  be  associated  with  a  gouty  diathesis  or  to  have 
folloM'ed  syphilis;  and  at  any  age  it  may  be  secondary  to  other 
diseases  of  the  liver,  and  is  then  apt  to  be  lasting. 

Generally  catarrhal  icterus  is  a  tractable  disorder ;  and  after 
continuing  for  two  or  three  weeks,  it  usually  subsides.  But  it 
may  persist  for  as  many  months;  and  in  rare  instances  the  inflam- 
mation leads  to  an  occlusion  of  the  bile-ducts,  and  to  a  fatal  issue. 
I  had  such  a  case  in  1863  under  my  charge  at  the  Philadelphia 
Hospital.  The  patient,  a  man  upwards  of  sixty  years  of  age,  died 
deeply  jaundiced  and  comatose.  He  had  presented,  during  life, 
the  signs  of  enlargement  of  the  liver ;  little  or  no  tenderness  in 
the  hepatic  region ;  no  fever ;  but  much  gastric  irritability  and 


DISEASES   OF   THE   LIVER,  605 

obstinate  constipation,  both  of  which  had  existed  for  three  weeks 
prior  to  a  noticeable  discoloration  of  the  skin.  The  whole  disease 
was,  as  far  as  conld  be  ascertained,  of  only  two  months'  duration  ; 
and  the  jaundice  steadily  deepened  from  the  time  of  its  first  ap- 
pearance. At  the  autopsy,  the  gall-bladder  was  found  enormously 
distended,  its  coats  thin,  yet  otherwise  scarcely  abnormal ;  but  the 
common  duct  was  obliterated  by  inflammation.  The  stomach  and 
the  upper  bowel  were  congested,  while  the  coats  of  the  stomach 
toward  the  pylorus  were  thickened.  A  similar  case  has  been 
described  by  Tyson.* 

Now,  in  point  of  diagnosis,  it  is  not  generally  difficult  to  dis- 
tinguish the  catarrhal  inflammation  of  the  gall-bladder,  except  in 
those  rare  instances  in  which  the  common  duct  or  the  hepatic  duct 
is  obliterated.  It  differs  from  hepatic  inflammation  chiefly  by  the 
marked  jaundice  and  by  the  absence  of  fever  and  of  grave  consti- 
tutional disturbance ;  from  the  ordinary  congestion  of  the  liver,  by 
the  different  etiological  elements  in  the  history  of  the  case, — the 
one  disorder  happening  most  commonly  in  connection  with  disease 
of  the  heart,  or  an  obstruction  of  the  portal  circulation,  or  a  mias- 
matic poison,  the  other  following  most  usually  exposure  to  cold 
and  damp,  or  the  eating  of  quantities  of  indigestible  food,  or  oc- 
curring in  an  epidemic  form.  Then,  inflammation  of  the  gall- 
ducts  gives  rise  to  much  more  jaundice.  Further,  we  must  not 
forget  that  what  is  called  congestion  is  often  really  the  disease  we 
are  discussing. 

Catarrhal  jaundice  may  occur  as  an  accompaniment  of  some 
general  morbid  condition,  and  in  an  epidemic  form.  These  cases 
are  distinguished  by  the  history,  by  the  tendency  to  acute  disease 
of  other  organs,  such  as  the  lungs  and  kidneys,  and  by  enlarge- 
ment of  the  spleen. f 

From  the  jaundice  of  chronic  hepatic  maladies — such  as  cancer 
or  cirrhosis — we  separate  catarrhal  icterus  by  the  non-existence  of 
the  physical  signs  of  these  maladies,  by  its  acute  course,  and  by 
the  dissimilar  progress  of  the  symptoms.  Still,  as  regards  cancer 
we  must  bear  in  mind  that  we  encounter  in  elderly  gouty  persons 
cases  of  long-persisting  catarrhal  icterus  attended  with  frequent 


*  Transactions  of  the  Pathological  Society  of  Philadelphia,  vol.  iv, 
t  Heitter,  Wien.  Med.  Wochenschr.,  1887. 


606  MEDICAL    DIAGNOSIS. 

vomiting-  and  marked  emaciation  whieh  8ti\)ngly  resemhle  eancer, 
yet  slowly  yield  to  tri'atment.  Intlannnation  of  the  biliary  pas- 
s;iges  with  tiie  janndiee  arir^ing  in  consequence  of  hiUary  calcuH  is 
distinguished  by  the  severe  pain,  the  sudden  appearance  of  the 
icterus  subsequent  to  the  paroxysms  of  pain,  its  increase  after 
them,  and  its  often  rapid  fading  after  the  gall-stone  is  voided. 
The  sym})toms  of  the  early  stages  of  acute  atrophy  of  the  liver,  as 
well  as  those  of  some  cases  of  acute  inflammation,  may  be  so  like 
the  symptoms  of  inflammation  of  the  gall-bladder  and  gall-ducts 
that  their  discrimination  is  for  a  time  impossible;  but  the  phe- 
nomena which  soon  follow  clear  up  the  obscurity. 

In  some  cases  of  inflammation  of  the  biliary  ducts,  especially 
where  an  occlusion  of  the  ducts  takes  place,  a  peculiar  parox- 
ysmal fever  is  developed,  with  temperature  ranging  from  103°  to 
105°,  which  might  readily  be  mistaken  for  a  malarial  outbreak. 
This  hepatic  fever  is  generally  ushered  in  by  a  violent  chill,  and 
the  paroxysms,  M'hich  are  repeated  at  irregular  times,  are  apt  to 
be  followed  by  increased  jaundice.  Their  irregularity,  their  re- 
sistance to  quinine,  the  frequent  occurrence  of  vomiting  and  of 
pain  in  the  region  of  the  liver,  and  the  history  of  the  case,  distin- 
guish them  from  malarial  fever.  From  abscess  of  the  liver  the 
affection  is  more  difficult  to  discriminate,  and  we  must  lay  stress  on 
the  deep  jaundice,  which  mostly  happens  after  the  fever-outbreaks, 
and  on  the  different  physical  phenomena.  Sweats  occur  in  both, 
but  they  only  occur  at  the  end  of  the  marked  paroxysm  in  the 
so-called  hepatic  fever.  The  febrile  attacks  are  explained  by 
Pepper  *  as  mostly  due  to  a  purulent  lesion  at  some  point  of  the 
biliary  canals,  or  to  the  development  of  ptomaines,  owing  to  the 
ptomaine-destroying  function  of  the  liver  being  interfered  with 
wh€!n  the  bile  is  pent  up.  We  also  find  similar  attacks  of  rigors 
and  intermittent  pyrexia  associated  with  hepatic  pain  in  obstruc- 
tion of  the  common  bile-duct  from  gall-stones.  Charcot  looks 
upon  them  as  septic,  as  does  Osier ;  f  Ord  |  holds  the  fever-outbreak 
to  be  a  reflex  phenomenon. 

Now,  considering  the  question  of  operative  interference  that 


*  Medical  News,  March  29,  1890. 

f  Johns  Hopkins  Hospital  Reports,  vol.  ii.  No.  ] ,  1890. 

X  Boston  Med.  Journ.,  1887. 


DISEASES   OF   THE   LIVER.  607 

may  arise,  it  is  of  the  utmost  importanee  to  distinguisli  tlie  cases 
where  the  obstruction  is  purely  catarrhal  and  not  connected  with 
gall-stones  from  those  in  which  it  is.  The  most  certain  t(;st  un- 
doubtedly would  be  having  found  gall-stones  on  previous  occa- 
sions. But,  besides,  the  cases  with  gall-stones  are  very  much  more 
frequent  than  the  cases  of  hepatic  fever  without ;  the  jaundice  is 
more  distinctly  connected  with  the  attacks,  and  generally  passes 
off  more  completely  between  them ;  the  pain  is  greater  and  ceases 
more  abruptly  ;  and  the  febrile  paroxysms  are  not  brought  on  by 
cold,  exposure,  and  fatigue,  as  they  are  often  in  the  hepatic  fever 
without  gall-stones. 

Acute  Diseases  characterized  by  a  Decrease  in  the  Size  of  the 
Liver  and  by  Deep  Jaundice. 

Acute  Yellow  Atrophy. — This  dangerous  affection  consists 
in  a  rapid  diminution  of  the  liver,  with  disintegration  in  the 
secreting-cells.  Its  functions  are  almost  wholly  suspended,  and 
the  evil  effects  of  the  accumulation  of  the  elements  of  the  bile  in 
the  blood  show  themselves  in  the  deep  jaundice  and  in  the  pro- 
found disturbance  of  the  nervous  system.  To  this  disease  belong- 
most  of  those  cases  of  malignant  jaundice  which  terminate  rapidly 
in  death  after  violent  cerebral  symptoms.  The  malady  scarcely 
ever  lasts  a  week ;  generally  a  few  days  only  elapse  before  the 
patient  becomes  comatose  and  dies. 

The  complaint  is  sometimes  ushered  in  by  nausea,  a  coated 
tongue,  irregular  action  of  the  bowels,  and  a  frequent  pulse ;  at 
other  times  it  begins  abruptly  with  pain  in  the  head,  and  with 
vomiting,  at  first  of  the  contents  of  the  stomach,  but  soon  of 
coffee-ground  material,  which  is  evidently  altered  blood.  The 
skin  is  yellow,  and  becomes  from  hour  to  hour  more  discolored. 
Jaundice  is,  indeed,  never  absent :  it  may  not  make  its  appearance 
before  the  other  urgent  symptoms,  but  sometimes  it  precedes  the 
signs  of  serious  difficulty  for  several  days,  or  even  for  longer, — 
perhaps  for  upwards  of  two  weeks.*  That  the  jaundice  is  not  due 
to  obstruction  is  proved  by  the  stools  containing  bile.  There  are 
not  uncommonly  pain  at  the  epigastrium  and  in  the  hepatic  region, 

*  As  in  Observation  No.  XVII.  of  Frerichs  on  Diseases  of  the  Liver. 


608  MEDICAL   DIAGNOSIS. 

muscular  and  arthritic  pains,  dvspntva,  nictoorism,  enlargement 
of  the  spleen,  epistaxis,  and  hemorrhage  from  the  bowels.  The 
pulse  exhibits  extraordinary  changes:  it  is  generally  very  rapid, 
but  sinks  at  times,  without  any  assignable  reason,  to  a  normal  fre- 
quency;  during  the  deep  coma  of  the  last  stages  of  the  malady  the 
beat  of  the  artery  is  apt  to  become  slow  and  full,  but  it  may  be 
very  quick  and  very  small.  There  is  fever,  not,  however,  active 
or  presenting  a  marked  rise  in  the  temperature;  this  may  be,  in- 
deed, after  the  early  stages  of  the  disease,  below  the  norm.  The 
surface  may  be  covered  with  petechise,  on  account  of  the  dissolu- 
tion of  the  blood.  But,  if  we  exce})t  pcrhai)S  the  deep  jaundice 
and  the  lessening  hepatic  dulness,  the  most  significant  symptoms 
arc  tliosc  referable  to  the  nervous  system.  Severe  headache,  de- 
lirium, involuntary  discharges,  tremors,  spasms,  convulsions,  or  a 
constantly-increasing  stupor  and  sluggish  pupils,  show  clearly  what 
disturbance  the  poisoned  blood  is  creating  in  the  nervous  centres. 

Acute  atrophy  of  the  liver  scarcely  happens  in  children  or  after 
forty  years  of  age,  and  is  much  more  common  in  women  than  in 
men.  We  find  it  not  unusually  following  violent  mental  emotions 
or  drunkenness  and  venereal  excesses;  or  it  occurs  during  preg- 
nancy, and  is  then  accompanied  by  renal  disorder. 

Now,  how  does  this  fatal  malady  differ  from  acute  inflammation 
of  the  liver  ?  By  the  marked  jaundice,  the  cerebral  symptoms, 
the  rapid  diminution  in  the  volume  of  the  liver,  the  dry,  brown 
tongue,  the  frequent,  changeable  pulse,  and  the  occurrence  of  hem- 
orrhages. Then  the  circumstances  under  which  acute  atrophy 
makes  its  appearance  are  very  dissimilar.  Indeed,  the  diagnosis 
is  not  generally  a  difficult  one, — not  nearly  so  difficult  as  between 
acute  atrophy  and  typhoid  fever,  or  between  the  former  affection 
and  yellow  fever  or  certain  local  diseases,  such  as  peritonitis,  pneu- 
monia, and  meningitis,  when  accompanied  by  jaundice  and  de- 
lirium. The  character  of  the  eruption,  the  presence  of  diarrhoea 
instead  of  constipation,  the  milder  nature  of  the  mental  wandering, 
the  significant  temperature  record,  and  the  slower  progress  of  the 
disease  are  of  much  value  in  enabling  us  to  distinguish  between 
typhoid  fever  and  the  typhoid  symptoms  of  acute  yellow  atrophy 
of  the  liver.  From  yeUoic  fever,  acute  atrophy  differs  by  the  epi- 
demic character  of  the  former,  by  the  injected  eye,  by  the  intense 
pain  in  the  back,  limbs,  and  forehead,  by  the  stages  the  febrile 


DISEASES   OF   THE   LIVER.  G09 

malady  presents,  by  the  decided  fever  temperature,  hy  the  com- 
parative absence  of  cerebral  symptoms,  and  by  the  enlargement 
rather  than  the  atrophy  of  the  liver. 

From  the  other  affections  named,  the  hepatic  disorder  may  be 
discriminated  by  a  thorough  examination  of  the  various  organs 
of  the  body,  and  by  a  careful  weighing  of  all  the  symptoms.  In 
truth,  it  is  thus  only  that  we  can  avoid  error ;  since,  unless  we  can 
establish  the  most  positive  sign  of  acute  atrophy,  the  diminution 
of  the  area  of  percussion  dulness  of  the  liver, — and  there  are 
cases  in  which  we  cannot  establish  this,  particularly  if  there  have 
been  enlargement  from  previous  disease,* — there  is  no  manifesta- 
tion of  the  hepatic  malady  that  may  not  occur  in  the  diseases 
mentioned,  when  they  are  complicated  by  jaundice.  It  is  true 
that  vomiting  of  blood  is  scarcely  among  their  symptoms ;  but 
this  does  not  invariably  happen  in  acute  atrophy.  In  many  cases 
of  doubt  we  may  seek  in  the  urinary  secretion  for  the  sediments 
of  tyrosine  or  for  leucine ;  and  test  for  urea,  which  is  greatly  de- 
ficient or  absent.  So  may  be  the  uric  acid,  the  chlorides,  the  sul- 
phates, and  the  earthy  phosphates.  We  may  in  this  connection 
remark  that  leucine  and  tyrosine  have  also  been  found  in  the  blood 
and  in  many  tissues  of  the  body.  This  happened  in  a  case  which 
I  saw  with  Dr.  H.  C.  Wood,  and  which  he  has  carefully  reported. f 

Acute  yellow  atrophy  may  happen  occasionally  in  children.^ 
An  affection  like  it  occurs  from  phosphorus-poisoning ;  and  in- 
deed there  are  those  who  believe  that  acute  yellow  atrophy  is  really 
due  to  phosphorus  accidentally  introduced  into  the  system. §  The 
occurrence  of  the  fatal  malady  in  pregnant  women  has  already 
been  referred  to.  Jaundice  from  mental  emotion,  or  produced  by 
the  pressure  of  the  gravid  womb,  is  in  them  not  unusual ;  and  we 
may  be  called  upon  to  distinguish  this  harmless  form  of  icterus 
from  that  of  yellow  atrophy.  In  the  serious  derangement  of  the 
nervous  system,  and  the  graver  character  of  all  the  symptoms,  lie 
the  marks  of  separation. 

*  As  in  a  case  in  my  ward  at  the  Pennsylvania  Hospital. 

t  Amer.  Journ.  Med.  Sci.,  April,  1867. 

X  Duckworth,  St.  Barthol.  Hosp.  Rep.,  vol.  vi.  ;  Tuckwell,  ib.,  vol.  x.,  1874. 

I  Perls,  Handb.  d.  AUg.  Pathol.,  i.,  points  out  an  anatomical  distinction  : 
in  acute  atrophy  there  is  fatty  degeneration  ;  in  phosphorus-poisoning  the 
liver-cells  are  only  infiltrated  with  fat. 

39 


610  MEDICAL   DIAGNOSIS. 

Chronic  Diseases  attended  with  Enlargement  of  the  Liver,  and 
with  slight  or  no  Jaundice. 

Chronic  Congestion. —  riii;?  morbid  condition  is  observed 
chiefly  in  persons  of  sedentary  habits,  or  in  those  avIio  indnlge 
too  freely  in  tlie  pleasures  of  tlie  table,  or  use  large  quantities  of 
alcoholic  drinks  or  fermented  liquors.  It  is  frequently  met  with 
in  hot  climates  and  in  malarial  districts.  It  may  also  occur  in 
scurvy,  and  in  connection  with  abdominal  affections  whieli  inter- 
fere with  the  portal  circulation,  or  it  may  happen  in  consequence 
of  a  disturbance  of  the  flow  of  blood  through  the  liver,  dependent 
upon  disease  of  the  heart. 

Whatever  the  source  of  the  hypersemia,  the  symptoms  are  sim- 
ilar. They  are  impaired  appetite,  bitter  taste  in  the  mouth,  a 
coated  tongue,  flatulency,  a  feeling  of  tension  and  weight  in  the 
right  hypochondrium,  depression  of  spirits,  loss  of  strengtli,  im- 
poverishment of  blood,  deposits  of  lithates  in  the  highly-colored 
urine  on  cooling,  headache,  diy  cough,  and  occasional  nausea  and 
diarrhoea,  or  looseness  of  the  bowels  alternating  with  constipation, 
and,  in  protracted  cases,  hemorrhoids.  The  conjunctiva  has  con- 
stantly a  more  or  less  jaundiced  tinge ;  the  dulness  on  percussion 
in  the  hepatic  region  is  increased  in  extent.  In  some  cases  the 
habitual  congestion  leads  to  an  altered  condition  of  the  bile-ducts 
and  of  the  secreting-cells  of  the  liver ;  but  ordinarily,  unless  the 
hyperemia  be  kept  up  by  some  exciting  qause  which  it  is  impos- 
sible to  remedy, — such  as  an  abdominal  tumor,  or  an  organic 
affection  of  the  heart, — we  can,  by  a  carefully-regulated  diet  and 
by  active  exercise  in  the  open  air,  together  with  the  use  of  laxa- 
tives, restrain  the  congestion,  and,  indeed,  in  time  remove  it.  A 
troublesome  feature  of  the  malady  is  its  disposition  to  return. 

By  attention  to  the  signs  mentioned,  there  is  usually  little  dif- 
ficulty in  recognizing  chronic  hepatic  congestion.  How  it  may 
be  discriminated  from  other  forms  of  enlargement  of  the  liver, 
we  shall  presently  inquire.  It  is  sometimes  confounded  with,  or 
rather  there  is  sometimes  mistaken  for  it,  a  liver  which  has  been 
pushed  downwaixi  by  the  habit  of  tight  lacing.  But  the  absence 
of  any  signs  of  hepatic  derangement,  and  the  lowered  outline  of 
the  upper  border  of  the  displaced  right  lobe,  will  generally  enable 
us  to  distinccuish  this  state  from  chronic  congestion  of  the  liver. 


DISEASES   OF   THE   LIVER.  Gil 

Chronic  hepatic  congestion,  as  indeed  any  disease  of  the  liver 
which  leads  to  its  enlargement,  may  be  confounded  with  cJironic 
gastritis.  The  error  is  most  likely  to  occur  in  those  cases  of  en- 
larged liver  in  which  there  is  pain  on  pressure.  But  the  outline 
of  the  dulness  when  the  liver  is  increased  in  size,  the  jaundiced 
hue  of  the  conjunctiva,  the  altered  character  of  the  stools,  and, 
on  the  other  hand,  the  more  marked  indigestion,  and  the  fulness 
and  tenderness  being  equally  perceived  in  positions  to  which  the 
liver,  unless  greatly  augmented,  does  not  extend,  will  ordinarily 
enable  us  to  arrive  at  a  correct  diagnosis.  Yet  we  must  not 
forget  that  the  two  morbid  states  may  be  conjoined. 

Hypertrophy  of  the  liver  may  present  the  manifestations  of 
congestion.  The  little  we  know  of  an  increased  formation  of  the 
liver-cells  teaches  ns  that  this  may  happen  as  a  partial  hyper- 
trophy, to  compensate  for  loss  of  substance,  in  instances  in  which 
a  portion  of  the  gland  has  been  destroyed ;  or  as  a  more  general 
increased  growth  in  diabetes,  in  leukaemia,  and  as  a  consequence 
of  malaria.  Perhaps  the  history  of  the  case  may  enable  us  to 
arrive  at  the  discrimination  of  the  rare  disease.  Yet  there  is 
never  any  certainty  in  the  diagnosis. 

So-called  torpor  of  the  liver,  in  which  there  is  supposed  to  be  a 
deficient  excretion  of  bile,  has  much  the  same  symptoms  as  con- 
gestion. Indeed,  it  is  a  question  whether  this  is  not  often  present 
as  at  least  a  secondary  result.  In  persons  of  middle  life  who  eat 
freely  and  take  too  little  exercise  in  the  open  air,  or  those  of  sed- 
entary habits  in  whom  anxiety  and  worry  have  lowered  the  nervous 
tone,  the  well-known  symptoms  of  headache,  languor,  depression 
of  spirits,  loss  of  appetite,  drowsiness  after  meals,  sallow  hue  of 
skin,  dingy  conjunctiva,  urine  depositing  lithates,  stools  black  and 
offensive,  or  more  often  pale  or  whitish,  bespeak  this  "bilious" 
state,  and  we  can  only  distinguish  the  functional  disorder  from 
the  ordinary  forms  of  chronic  congestion  by  the  history,  the  con- 
current symptoms,  the  tension  in  the  region  of  the  liver,  and  the 
enlargement  of  the  organ,  which  these  present. 

The  symptoms  of  chronic  congestion  of  the  liver,  as  indeed  of 
other  hepatic  derangements,  show  themselves  at  times  more  par- 
ticularly in  the  nervous  system.  Headache,  vertigo,  dimness  of 
sight,  and  noises  in  the  ears  are  common  ;  and  I  have  often  known 
the  same  to  happen  that  Murchison  states  to  be  not  infrequent,- — 


612  MEDICAL    DIAGNOSIS. 

I  have  known  tingling  and  pricking  sensations  and  a  I'celing  of 
creeping  in  the  extremities  canse  needless  alarm  that  paralysis  was 
imminent,  and  disajipear  nnder  blue  pill  and  a  few  saline  pur- 
gatives.    On  the  other  hand,  we  nnist  be  careful  not  to  regard 
as  evidencx?  of  an  hepatic  disorder  signs  of  stomach  and  liver  de- 
rangement which  are  really  due  to  an  affection  of  the  nervous 
system.     Twice  it  has  come  under  my  observation   that  altered 
character  of  the  stools,  bitter  taste  in  the  mouth,  vomiting,  and 
slight  discoloration  of  the  conjunctiva,  existing  in  connection  with 
tumors  at  the  base  of  the   brain,  were  considered  as  purely  of 
hepatic  origin.     Clifford  Allbutt*  cites  a  case  of  Meniere's  dis- 
ease, in  the  person  of  a  physician,  where  the  vomiting  and  giddi- 
ness received  this  false  explanation.     In  such  instances,  of  course, 
attention  to  the  occurrence  of  disordered  gait,  and  of  the  persistent 
noises  in  one  or  both  ears,  and  to  the  loss  of  power  of  hearing  of  one 
ear,  shown  when  a  tuning-fork  is  placed  in  contact  with  the  skull 
on  the  affected  side,  tells  the  true  meaning  of  the  other  symptoms. 
Chronic  Hepatitis. — It  is  difficult  to  say  what  are  the  symp- 
toms of  the  malady,  because  most  of  the  chronic  affections  of  the 
organ,  especially  the  congested,  the  fatty,  the  albuminoid  liver, 
and  hypertrophic  cirrhosis,  are  by  some  included.     If,  following 
Audral,  we  call  only  that  state  chronic  inflammation  in  which  the 
liver  is  augmented  in  size,  harder  than  natural,  yet  easily  torn,  of 
deep-red  color,  and  in  which  the  exudation  is  apt  to  become  puru- 
lent, we  find  these  manifestations :  dull,  heavy  pain  in  the  hepatic 
region,  somewhat  augmented  by  pressure ;  dry,  heated  skin,  of 
sallow  hue,  and  often  the  seat  of  distressing  itching  ;  a  yellowish 
conjunctiva;  indigestion;  whitish  stools,  generally  hard ;  a  short 
cough ;  and  the  physical  signs  on  palpation  and  percussion  of  an 
enlaro;ed  liver,  the  border  of  which  is  uniformly  thickened  and 
hardened.      The  inflammation  may  be  chronic  almost  from  its 
onset,  and  be  developed  under  much  the  same  circumstances  as 
chronic  congestion ;  or  it  may  succeed  to  an  attack  of  acute  hepa- 
titis.    But  chronic  hepatitis  is  not  a  common  disease,  except  in 
hot  climates,  and  is  scarcely  to  be  distinguished  from  persistent 
hyperemia  of  the  organ,  unless  when  the  inflammation  leads  to 
the  formation  of  abscesses. 


*■  St.  George's  Hosp.  Kep.,  vol.  viii. 


DISEASES    OP   THE    LIVER.  613 

Abscess  of  the  Liver. — Hepatic  abscesses  may  form  as  the 
result  of  either  acute  or  chronic  inflammation  of  the  liver.  In 
the  tropics  this  is  not  unusual ;  in  temperate  climates  we  seldom 
encounter  the  affection^  save  as  the  consequence  of  metastatic  or 
pyemic  inflammation  of  the  liver,  or  in  connection  with  some 
disease  of  the  intestines,  or  as  a  sequel  of  gall-stones  which  have 
produced  ulceration  of  the  gall-bladder  and  gall-ducts,  and  sec- 
ondary abscesses  of  the  liver. 

The  symptoms  of  hepatic  abscess  are  obscure.  Sometimes 
the  only  symptoms  are  debility,  great  irritability  of  the  nervous 
system,  and  irregular  slight  febrile  attacks.  More  usually  the 
formation  of  pus  gives  rise  to  rigors,  leads  to  night-sweats,  and 
not  nnfrequently  to  the  development  of  a  fever  simulating  that 
of  a  quotidian  or  tertian  intermittent  or  remittent,  and  attended 
during  certain  hours  of  the  day  with  considerable  elevation  of 
temperature.  Jaundice  occurs,  but  is  generally  slight,  and  is 
often  absent.  There  is  no  enlargement  of  the  abdominal  veins, 
nor  is  there,  save  exceptionally,  ascites  or  oedema  of  the  lower  ex- 
tremities. Dry  cough,  quickened  breathing,  and  gastric  disorder, 
especially  loss  of  appetite,  are  frequent,  and  obstinate  vomiting, 
sing-ultus,  and  meteorism  are  not  unusual.  In  the  advanced 
stages  of  the  malady  typhoid  symptoms  are  apt  to  develop.  But 
the  disease  may  be  latent.  The  local  signs,  too,  are  far  from 
being  always  obvious,  or  indeed  uniform.  In  some  instances  the 
hepatic  region  is  more  prominent  than  natural,  and  we  can  detect 
fluctuation  over  portions  of  the  enlarged  gland ;  but  neither  sign 
is  constant,  and  the  latter  depends  greatly  upon  whether  or  not 
the  abscess  is  deeply  seated.  Tenderness,  either  general  or  limited, 
is  found  only  in  a  certain  proportion  of  cases,  especially  when 
the  abscess  is  near  the  surface.  It  is  frequently  associated  with 
a  throbbing  or  a  dull  pain,  which  may  be  transmitted  to  the  right 
shoulder.  According  to  Annesley,*  this  sympathetic  pain  in  the 
right  shoulder  indicates  that  the  convex  part  of  the  right  lobe  of 
the  viscus  is  affected.  Conjoined  to  the  feeling  of  weight,  and  to 
the  throbbing  in  the  hepatic  region,  is  at  times  a  tension  occasioned 
by  palpation  of  the  abdominal  muscles,  especially  of  the  rectus. 
Twining  f  regards  this  as  very  significant  of  deep-seated  abscess. 

*  Kesearches  into  the  Diseases  of  India.  f  Diseases  of  Bengal. 


G14  MEDICAL    DIAGNOSIS. 

Cyr*  tolls  us,  with  reference  to  the  exact  position  of  the  abscess, 
that  when  it  is  in  the  front  convex  part  of  the  liver  there  is  pain 
radiatinu-  to  the  chest  and  shoulder,  dyspnoea,  hut  rarely  jaun- 
dice ;  when  in  the  central  jiart  of  the  tn'gan,  there  are  few  signs 
of  local  atfectlon  of  the  liver  itself  or  adjacent  organs,  except  de- 
cided jaundice  if  the  abscess  be  large.  In  abscess  limited  to  the 
under  surface,  thoracic  symptoms  are  absent,  but  gastric  symp- 
toms, especially  uncontrollable  vomiting,  occur;  the  pain  is  apt 
to  radiate  towards  the  groin. 

A  positive  diagnosis  of  abscess  of  the  liver  is  often  a  very  diffi- 
cult matter ;  for  there  are  a  number  of  affections  with  which  it 
may  be  readily  confounded.  Prominent  among  these  are  hydatids, 
cancer  of  the  liver,  actinomycosis  of  the  liver,  affections  of  the 
gall-bladder,  and  a  pleuritic  effusion  on  the  right  side. 

From  Jtijdaflds  of  the  liver,  the  febrile  symptoms,  the  disturbed 
nutrition,  and  the  pain  distinguish  an  hepatic  abscess,  except  in 
those  cases  in  which  the  cyst  becomes  the  seat  of  suppuration. 
Under  these  circumstances  error  can  scarcely  be  avoided,  unless 
we  are  fully  cognizant  of  the  history  of  the  patient,  and  are  in 
possession  of  facts  furnishing  clear  evidence  as  to  the  state  of  the 
liver  prior  to  the  formation  of  pus. 

Cancer  of  the  liver  differs  from  an  abscess  by  its  dissimilar 
history,  by  the  hard  nodular  masses,  and  by  the  absence  of  fluc- 
tuation. It  is  only  in  rapidly-growing  medullary  cancer  that  we 
can  discern  a  sense  of  fluctuation;  but  even  here  we  can  generally 
distinguish  some  nodules  which  do  not  fluctuate;  and  should  the 
soft  cancerous  matter  impart  a  feeling  of  fluctuation,  it  is  rarely 
as  distinct  as  that  of  an  abscess.  Further,  the  marked  fever  and 
the  other  constitutional  symptoms  are  not  like  what  occur  in 
hepatic  cancer;  for  in  this  affection,  as  in  all  cancers,  the  tem- 
perature, excejjt  in  instances  of  large  rapidly-spreading  growths, 
is  but  little  affected, — may,  indeed,  be  subnormal. 

Actinomycosis  of  the  liver  may  give  rise  to  a  collection  of  pus, 
and  the  abscess  may  discharge  through  the  loins  or  through  the 
lungs,  as  in  hepatic  abscess.  The  hepatic  swelling  is  painful  on 
pressure,  but  is  unlike  that  of  hepatic  abscess  in  being  pallid,  in 
arising  suddenly  from  the  parts  beneath,  and  in  being  surrounded 

*  Traite  des  Maladies  du  Foie,  1887. 


DISEASES   OF   THE   LIVEU.  615 

by  a  firm  base  in  the  liver.     These  characters  distinguish  it  from 
an  ordinary  abscess  as  well  as  from  hydatid  of  the  liver.* 

Of  the  affections  of  the  gall-bladder,  the  one  most  liable  to  be 
confounded  with  hepatic  abscess  is  distention.  This  occurs  either 
from  a  closure  of  the  cystic  or  of  the  common  duct,  especially  the 
former,  or  from  an  inflammation  of  the  gall-bladder  itself,  and 
perhaps  a  subsequent  closure  of  the  ducts.  In  such  a  case  the 
gall-bladder  may  become  enormously  distended  with  decomposing 
bile  and  puriform  matter,  and  thus  may  be  occasioned  a  fluctu- 
ating tumor,  tender  on  pressure,  and  readily  mistaken  for  an 
abscess.  Now,  we  are  sometimes  able  to  distinguish  the  soft 
swelling  caused  by  a  diseased  gall-bladder  by  its  situation,  its 
pear-shaped  form,  its  mobility  and  the  absence  of  adhesions  to 
the  abdominal  walls,  its  distinct  and  persistent  fluctuations ;  by 
its  never  having  been  hard ;  by  the  normal  appearance  of  the 
parietes  of  the  abdomen ;  by  the  absence  of  tenderness  over  the 
liver,  merely  tenderness  over  the  tumor  being  found ;  and  by  the 
fact  that  affections  of  the  gall-bladder  are  frequently  preceded  by 
repeated  attacks  of  violent  pain  due  to  the  passage  of  biliary 
calculi,  or  by  bilious  fever.  Then  we  find  little  jaundice,  or 
none  at  all ;  and  no  hectic  fever.  But  to  neither  of  these  cir- 
cumstances can  we  trust  implicitly.  For  there  is  apt  to  be  in- 
tense jaundice  in  an  affection  of  the  gall-bladder,  if  the  common 
duct  also  be  implicated ;  and  jaundice  is,  in  abscess  of  the  liver,  a 
symptom  more  frequently  absent  than  present.  And  with  refer- 
ence to  hectic  fever,  the  continued  suppuration  in  the  distending 
sac  may  produce  it,  and  lead,  indeed,  to  great  constitutional  dis- 
turbance.f  Further,  these  biliary  abscesses  may,  like  hepatic 
abscesses,  open  externally,  or  burst  into  the  chest.  At  times  the 
communication  is  with  the  bronchial  tubes,  and  gives  rise  to  very 
anomalous  symptoms.  Thus,  Simmons  J  details  a  case  in  which 
there  was  a  circumscribed  tumor  in  the  epigastrium,  fluctuating 
with  a  sense  of  intervening  air  or  gas,  and  resonant  on  percus- 
sion ;  a  blowing  sound  was  distinctly  discerned  synchronous  with 
the  respiratory  act,  and  occasionally  accompanied  by  a  gurgling 

*  Harley,  Med.-Chir.  Transact.,  vol.  Ixix.,  1886. 

f  As  in  a  case  reported  by  Pepper  the  elder,  Amer.  Journ.  Med.  Sci., 
Jan.  1857. 

X  Amer.  Journ.  Med.  Sci.,  Oct.  1877. 


616  MEDICAL   DIAGNOSIS. 

noise ;  there  were  profuse  sweats  and  extreme  oppression,  but  no 
signs  of  pneumothorax.  At  the  autopsy  a  biliary  abscess  was 
found  communicating  with  the  right  bronchus. 

As  reg-ards  tlie  shape  of  the  swelling  due  to  an  enlarged  gall- 
bladder being  diagnostic,  we  must  bear  in  mind  that  it  may  be 
changed  by  contraction  of  the  muscular  coat. 

A  pleuritic  effusion  on  the  right  side  is  distinguished  from  an 
hepatic  abscess  by  the  same  phenomena  that  we  found,  in  discussing 
pleurisy,  to  separate  this  affection  from  all  forms  of  enlargement 
of  the  liver.  But  abscesses  of  the  liver  may  open  into  the  right 
pleural  cavity.  Then  we  observe  the  physical  signs  of  a  })leuritic 
effusion  subsequent  to  those  of  hepatic  abscess.  Generally,  too, 
the  pus  which  has  made  its  way  through  tlie  diaphragm  destroys 
the  lung-texture,  until  it  reaches  the  bronchial  tubes,  when  large 
quantities  of  purulent  sputa  are  expectorated ;  in  rarer  instances 
it  is  discharged  through  the  walls  of  the  chest.  In  the  former 
case,  the  accumulation  of  pus  in  the  pleura  may  be  very  limited ; 
the  inflammation  of  the  pleural  membrane  may  be  circumscribed, 
while  the  signs  of  an  inflammation  at  the  lower  portion  of  the 
right  lung,  dulness  on  percussion,  tubular  breathing,  and  rusty- 
colored  sputa,  are  evident.  These  phenomena  may  subside,  and 
the  respiration  in  parts  become  inaudible,  when  a  discharge  of  a 
large  quantity  of  a  reddish  or  whitish  pus  takes  place,  in  which 
the  elements  of  bile  and  the  microscopical  appearances  of  the 
hepatic  tissue  may  be  detected.  Gradually  this  expectoration 
ceases,  and  the  affected  textures  heal.  But  in  some  instances  the 
discharge  never  stops,  and  the  patient  dies  worn  out  by  the  con- 
stant drain. 

In  subphrenic  pyo-pneumothorax,  cavities  full  of  air  form  be- 
neath the  diaphragm  and  extend  into  the  thorax.  When  situated 
on  the  right  side  they  may  be  mistaken  for  the  breaking  of  an 
hepatic  abscess  into  the  chest.  The  history  of  the  affection  is 
generally  significant ;  the  subphrenic  abscesses  are  the  result  of 
perforating  ulcers  of  the  stomach  or  of  the  duodenum,  and  their 
development  is  preceded  by  the  symptoms  of  general  peritonitis 
or  by  the  discharge  of  pus  by  the  bowels.  The  signs  of  pneumo- 
thorax, as  Leyden*  has  found,  subsequently  show  themselves,  with 

*  Zeitschrift  fiir  Klin.  Med.,  Bd.  i. 


DISEASES   OF   THE   LIVER.  617 

distinct  metallic  tinkling  and  succussion  sound ;  yet,  while  all 
breath-sound  is  sharply  cut  off  below  the  fourth  or  fifth  rib,  up 
to  this  point  the  normal  vesicular  murmur  is  heard  on  deep  respi- 
ration, and  there  are  no  signs  of  pressure  in  the  pleural  cavity  or 
of  distention  of  the  chest,  and  the  marked  alteration,  by  change 
of  position,  of  the  dulness  on  percussion,  from  the  exudation  at 
the  lower  part  of  the  chest,  is  strictly  limited  to  this  part.  The 
liver  reaches  to  the  umbilicus  or  lower,  and  when  a  canula  is 
passed  into  the  cavity  beneath  the  diaphragm  and  a  manometer 
is  attached,  inspiration  shows  increased  pressure,  expiration  the 
reverse, — exactly  opposite,  therefore,  to  what  happens  if  the  canula 
be  in  the  pleura. 

When  an  hepatic  abscess  forces  its  way  externally,  it  may,  prior 
to  its  discharge  through  the  thoracic  or  abdominal  walls,  occasion 
difficulty  in  diagnosis  from  abscesses  originating  in  these  w^alls. 
Nothing  but  a  careful  consideration  of  the  attending  symptoms 
and  of  the  history  of  the  case  will  lead  to  a  differential  dis- 
tinction. Nor  does  the  difficulty  wholly  cease  when  the  slowly- 
developed  tumor,  which  an  hepatic  abscess  forms,  has  opened, 
since  it  is  far  from  always  that  we  find  in  the  pus  the  evidences  of 
the  broken-down  liver-tissue,  and  it  is  only  occasionally  that  the 
fluid  is  of  yellow  or  greenish  color  and  yields  the  reactions  of  bile. 
The  means  of  discrimination  most  to  be  relied  upon  is  a  probe ; 
for  by  the  depth  to  which  it  can  be  passed,  the  direction  it  takes, 
and  the  feel  of  the  structures  it  encounters,  we  are  placed  in 
possession  of  many  important  facts  bearing  on  the  diagnosis.  In 
doubtful  cases,  also,  we  may  employ  the  aspirator,  and  a  chemical 
and  microscopical  examination  of  the  pus,  other  than  that  oozing 
out  of  the  opening,  may  tell  the  nature  of  the  abscess.  Indeed, 
the  aspirator  may  be  made  a  means  of  diagnosis  of  abscess  of  the 
liver  under  some  of  the  circumstances  above  mentioned,  where 
abscess  is  closely  simulated  by  other  hepatic  affections.  If  no 
abscess  be  found,  no  particular  harm  results  from  the  explora- 
tion ;  nay,  it  has  even  been  affirmed  that  the  local  depletion  does 
good.* 

Occasionally  a  hernia  through  one  of  the  recti  muscles  is  mis- 
taken for  a  projecting  abscess  of  the  liver.     I  was  called  some 

*  Maclean,  Lancet,  July,  1873. 


618  MEDICAL   DIAGNOSIS. 

years  since  to  see  siieli  a  case,  in  which  the  opinion  that  it  was  an 
abscess  of  the  liver  had  been  long  entertained.  The  sound  of  the 
mass  on ,  percussion ;  the  clearly-defined  limits  of  the  liver ;  the 
absence  of  hepatic  and  gastric  symptoms, — taught  the  true  nature 
of  the  malady. 

Much  has  been  said  of  the  distinction  between  the  abscesses 
which  are  developed  in  the  course  of  pyaemia — "  the  pya^nic  ab- 
scess"— and  the  abscess,  connnon  in  tropical  climates,  mIucIi  forms 
as  the  result  of  hepatitis,  "the  tropical  abscess."  The  points  of 
distinction  may  be  thus  tabulated  : 

Pyemic  Abscess.  Tropical  Abscess. 

Many  in  number ;  small  in  size.  Usually  a  single  large  abscess. 

Unifonn  enlargement  of  liver;   only  Enlargement    not    uniform;    bulging 

exceptionally  bulging  of  ribs.  of  ribs,  or  in  epigastrium,  or  in  rigbt 

hypochondrium. 

No  fluctuation  ;  always  pain  and  ten-  Fluctuation   usual ;   pain  and  tender- 

derness.  ness  always  absent. 

Jaundice  present  in  the  majority  of  Jaundice  exceptional. 

cases. 

Enlargement  of  spleen  usual.  Enlargement  of  spleen  unusual. 

Kigoi"s    and     night-sweats     marked;  Kigors  and  night-sweats  less  marked; 

great    tendency    to    symptoms    of  obstinate  vomiting  often  present. 

blood-poisoning. 

Coui-se   rapid ;    three   weeks   to   three  Course   less   rapid ;    often   extends   to 

months.  three  or  six  months,  or  longer. 

Arises  after  external  injuries  and  oper-  Arises  in  tropical  climates,  chiefly  in 

ations,  or  internal  suppurating  cavi-  free    livers ;     dysentery     frequently 

ties  or  ulcerations,  such  as  ulcers  of  coexists. 

the  stomach  or  gall-bladder. 

Fatty  Liver. — A  fatty  liver  occurs  in  drunkards ;  in  persons 
who  lead  indolent  lives  and  are  large  eaters;  in  wasting  diseases, 
especially  in  phthisis ;  in  the  course  of  protracted  diarrhoea ;  and 
sometimes  in  children  after  exanthcmatous  fevers.  But  of  all 
these  causes,  pulmonary  consumption  is  the  most  common. 

A  knowledge  of  the  sources  of  fatty  liver  is  the  most  important 
element  in  the  diagnosis ;  for  neither  the  physical  signs  nor  the 
symptoms  present  anything  which  is  cHaracteristic.  The  physical 
signs  are  simply  those  of  an  enlarged  liver ;  the  enlargement  is 
generally  moderate  and  uniform,  and  the  lower  margin  rounded. 
In  thin  persons  it  may  be  possible  to  discern  the  doughy  consist- 
ence of  the  organ.     The  symptoms  are  much  the  same  as  those 


DISEASES   OF   THE    LIVER.  619 

of  hepatic  congestion,  except  that  there  is  perliaps  greater  ten- 
dency to  diarrhoea,  and  that  we  find  in  some  instances  a  pale, 
greasy-feeling  skin.  There  is  neither  pain  nor  ascites.  The 
amount  of  jaundice  is  always  very  slight ;  in  truth,  jaundice  is 
most  frequently  wanting.  Partly  in  consequence  of  the  absence 
of  this  important  symptom,  partly  because  of  the  little  apprecia- 
ble disturbance  a  fatty  liver  may  occasion,  this  morbid  state  at 
times  escapes  our  observation  entirely. 

Waxy  Liver. — A  peculiar  infiltration  into  the  structure  of  the 
liver,  or  its  degeneration  into  a  substance  rendering  it  firmer  and 
more  glistening,  gives  rise  to  that  appearance  of  the  liver  which 
is  variously  designated  as  waxy,  lardaceous,  amyloid,  albuminous, 
or  scrofulous  liver. 

The  symptoms  of  a  waxy  liver  are  those  of  an  hepatic  derange- 
ment which  manifests  itself  rather  by  the  signs  of  disturbance  of 
other  organs  than  by  the  direct  proof  of  altered  function  of  the 
viscus  really  aifected.  Thus,  disordered  digestion,  nausea,  vomit- 
ing, tympanites,  discolored  stools,  and  diarrhoea  are  much  more 
frequent  than  jaundice,  which,  indeed,  is  very  much  oftener  absent 
than  present.  There  is  a  feeling  of  fulness  in  the  hepatic  region, 
but  little  or  no  pain ;  while  physical  exploration  exhibits  an  in- 
creased percussion  dulness,  and  shows  the  dense  organ  to  have  a 
well-defined  though  somewhat  rounded  margin.  The  enlargement 
is  uniform,  but  considerable ;  at  times  so  great  that  the  liver  oc- 
cupies a  large  part  of  the  abdomen,  producing  a  visible  bulging. 
The  smoothness  and  the  regularity  of  outline  are  lost  if  waxy 
liver  coexist  with  diseases  of  the  liver  which  may  harden  the 
organ  in  nodules,  such  as  cancer,  fibroid  changes,  or  cirrhosis. 

Enlargement  of  the  spleen  is  commonly  associated  with  the 
enlargement  of  the  liver,  and  in  many  cases  the  urine  is  albumi- 
nous from  waxy  disease  of  the  kidneys.  Dropsy,  as  a  rule,  is  not 
encountered ;  but  in  this  respect  much  depends  upon  the  state  of 
the  kidneys  and  of  the  blood,  or  upon  the  existence  of  secondary 
peritonitis. 

The  etiology  of  a  waxy  liver  teaches  us  that  it  is  very  much 
more  common  in  males  than  in  females  ;  that  the  malady  is  usu- 
ally caused  by  constitutional  syphilis ;  that  in  rarer  instances  it 
is  produced  by  tuberculosis ;  also  that  it  coexists  \vith  scrofulous 
diseases  of  the  bones,  with  unhealed  ulcers,  with  discharo-es  from 


620  MEDICAL   DIAGNOSIS. 

or  collections  of  pus  in  various  parts  of  the  body,  Avith  repeated 
attacks  of  intermittent  fever ;  or  that  it  results,  perhaps,  from  the 
abuse  of  mercury.  In  some  cases  we  cannot  trace  the  pathological 
process  to  any  known  cause ;  yet  even  in  these  cases  we  find  it 
attendcxl  with  signs  of  impaired  nutrition  and  occurring  in  persons 
evidently  cachectic. 

The  disease  is  one  lasting  for  years.  In  advanced  cases, 
besides  the  spleen  and  the  kidneys,  the  stomach  and  the  intes- 
tines are  apt  to  be  implicated ;  looseness  of  bowels,  \vith  dys- 
enteric symptoms,  arises,  and  the  skin  and  breath  have  a  musty, 
disagreeable  odor. 

Now,  when  we  contrast  a  waxy  liver  with  other  hepatic  com- 
plaints in  which  the  liver  is  enlarged,  we  find  it  resembling  most 
closely  the /a/'f^  and  the  6'yj:)/w7<7ic  affections.  But  in  the  former, 
although  there  is  enlargement,  thei*e  is  not  often  so  much  increase 
in  volume  as  in  the  waxy  liver.  Besides,  the  organ  feels  softer 
on  palpation,  and  the  disorder  is  not  associated  with  a  diseased 
spleen  or  kidney,  and  is  still  less  likely  than  a  wax}^  liver  to 
give  rise  to  dropsy.  Then  the  history  of  the.  case  is  very  sig- 
nificant. A  syphilitic  hepatitis,  with  which  indeed  the  waxy 
liver  is  at  times  combined,  is  mainly  distinguished  by  the  promi- 
nent nodules  felt  on  the  surface  of  the  liver.  From  congestion 
of  the  liver,  waxy  liver  is  readily  discriminated.  A  compara- 
tively slight  affection  in  which  jaundice  is  frequent  is  very  different 
from  a  malady  in  which  the  hepatic  disease  forms  but  part  of  a 
general  cachexia  and  in  which  jaundice  is  very  infrequent. 

Cancer  of  the  Liver. — In  cancer  of  the  liver  the  organ  is 
almost  invariably  large,  and  sometimes  it  reaches  an  enormous 
volume.  The  form  of  the  gland,  too,  is  altered.  It  is  irregular 
and  uneven,  nodules  of  various  size  being  developed  in  its  sub- 
stance and  projecting  from  its  border  and  surfaces.  These  prom- 
inences are  harder  than  the  surrounding  hepatic  tissue  ;  Ijut  there 
are  exceptions  to  this  rule,  for  sometimes,  especially  in  the  en- 
cephaloid  variety,  the  elastic  tumors  impart,  when  pressed,  a  very 
deceptive  sense  of  fluctuation.  The  cancerous  masses  increase, 
and  in  some  cases  Avith  great  ra])idity. 

The  malignant  disease  is  rarely  confined  to  the  liver ;  it  fre- 
quently supervenes  upon  cancer  of  the  mammary  gland  or  of 
the  uterus  or  of  the  stomach.     It  is  an  affection  pre-eminently 


DISEASES    OF    THE    LIVER.  621 

of  middle  life  or  of  old  age  ;  yet  it  occasionally  occurs  in  young 
persons.  I  have  met  with  two  cases  of  primary  cancer  of  the 
liver  in  women  not  twenty-five  years  of  age,  and  two  in  children. 
In  primary  cancer  of  the  liver  we  generally  find  a  history  of 
cancer  in  the  family  ;  and  protracted  grief  or  anxiety,  Murchison 
tells  us,*  precedes  the  development  of  the  malady,  whether  a 
family  taint  can  be  traced  or  not.  The  disease  rarely  lasts  beyond 
a  year,  and  it  may  run  a  lapid  course. 

Now,  many  of  the  pathological  facts  just  mentioned  have  a 
strong  bearing  on  the  diagnosis  of  hepatic  cancer.  They  espe- 
cially throw  light  on  the  most  important  signs  of  the  malady, — 
to  wit,  the  increased  percussion  dulness  in  the  hepatic  region,  and 
the  uneven  surface  detected  on  palpation.  The  enlarged  liver  is 
found  extending  across  the  epigastrium  far  into  the  left  hypo- 
chondrium  ;  it  reaches  at  times  lower  than  the  umbilicus,  and 
presses  the  diaphragm  npward.  The  nodules  can  often  be  felt 
distinctly  through  the  abdominal  walls.  The  diseased  organ  is 
painful,  and  tender  to  the  touch.  In  cases  in  which  the  peritoneal 
covering  is  affected,  the  tenderness  is  greatest.  And,  although 
any  of  these  three  phenomena — the  enlargement,  the  uneven 
surface,  and  the  tenderness — may  be  absent,  they  are  tolerably 
constant  attendants  on  cancer  of  the  liver.  The  tenderness  is, 
I  think,  the  sign  least  freqnently  wanting. 

Among  the  symptoms  of  hepatic  cancer,  we  find  gastric  and 
intestinal  disturbances;  pain  in  the  right  shoulder;  rigidity  of  the 
abdominal  muscles  ;  a  disordered  nutrition  of  the  whole  body  ;  a 
cachectic  look ;  occasional  febrile  attacks,  yet,  on  the  whole,  nor- 
mal or  subnormal  temperature ;  and,  in  the  later  stages,  some- 
times hemorrhages  from  the  stomach  or  bowels,  and  diarrhoea. 
Ascites,  too,  is  observed  among  the  symptoms  of  the  malignant 
malady,  and  is  generally  dependent  either  upon  chronic  peritonitis 
attending  the  development  of  the  cancer,  or  upon  the  pressure  this 
exerts  upon  the  larger  branches  of  the  portal  vein.  Jaundice  may 
or  may  not  be  present ;  it  is  most  frequently  wanting.  I  have 
seen  it,  however,  intense  when  the  cancerous  growth  presses  on 
the  bile-ducts  :  in  any  instance  in  which  it  occurs  it  persists  until 
death.    There  are  cases  in  which  all  these  symptoms  are  perceived; 

*  Lectures  on  Diseases  of  the  Liver,  2d  edit. 


622  MEDICAL   DIAGNOSIS. 

M'liile  in  others  only  some  occur,  and  in  others,  again,  even  these 
few,  may  not  be  avcII  defined.  Indeed,  when  we  consider  the 
amount  ^^f'  dcpdsit  m  hich  is  generally  present ;  w  hen  we  regard 
its  character;  M'hen  we  take  into  account  the  necessarily  impaired 
function  of  one  of  the  most  important  glands  in  the  body  ;  when 
we  reflect  upon  the  pressure  which  the  enlarged  organ  must  occa- 
sion,— it  is  truly  astonishing  that  oiten  so  little  dropsy,  so  little 
jaundice,  so  little  pain,  so  little  constitutional  disturbance,  are 
produced  by  the  disease. 

Yet  in  point  of  diagnosis  we  can  generally  discern  the  malady 
by  the  combination  of  the  symptoms  and  signs  indicated.  It  is 
only  at  an  early  stage  of  the  disease,  or  Mhen  the  liver  is  not 
enlarged,  that  we  are  apt  to  be  in  doubt.  Under  the  former  cir- 
cumstance, a  swelling  in  the  hepatic  region,  pain  upon  pressure, 
associated  with  retching,  with  nausea  and  vomiting,  and  with  fail- 
ing health  and  strength,  occurring  in  a  person  above  forty  years 
of  age,  n)ay  well  excite  our  suspicion.  But,  unless  there  be  a  his- 
tory of  cancer  in  the  family  or  a  cancer  in  some  other  part  of  the 
body,  we  cannot  be  certain  that  the  beginning  swelling  in  the  right 
hypochondrium  is  malignant.  When  the  liver  is  the  seat  of  cancer, 
but  is  not  increased  in  size,  the  recognition  of  the  malady  is  next 
to  impossible.  In  these  obscure  cases,  the  persistent  tenderness  in 
the  hepatic  region,  accompanying  the  evidences  of  disturbed  func- 
tion of  the  liver,  ascites,  anaemia,  and  a  cachectic  apjjcarance,  are 
the  signs  most  trustworthy  and  most  likely  to  lead  to  a  correct  con- 
clusion. In  any  instance,  jaundice  coming  on  in  a  person  over 
forty  years  of  age,  lasting  for  months,  and  associated  Avith  gastric 
disease  and  failing  health,  must,  in  the  absence  of  a  history  of 
gout  or  of  syphilis,  be  looked  upon  as  pointing  to  hepatic  cancer. 
Again,  we  must  remember  that  loss  of  flesh  and  of  strength  not 
unfrecjuently  precedes  jaundice  and  pain, — in  fact,  all  signs  of  dis- 
order of  the  aifected  organ. 

Let  us  pass  in  review  the  complaints  with  which  well-marked 
cancer  of  the  liver  may  be  confounded.  Omitting,  because  else- 
where discussed,  hydatids,  abscess  of  the  liver,  and  cirrhosis,  they 
are  : 

Waxy  Liver;  Fatty  Liver;  Chronic  Coxgestion. 

Acute  Coxgestiox  ;  Acute  Hepatitis;,  Catarrhal 
Jaundice. 


diseases  of  the  liver.  623 

Syphilitic  Liver; 

Affections  of  the  Gall-Bladdee  ; 

Cancer  of  the  Stomach; 

Cancer  of  the  Omentum  ; 

Enlargement  of  the  Right  Kidney. 

Waxy  Liver;  Fatty  Liver;  Chronic  Congestion. — A  waxy  liver 
presents  often  as  much  increase  in  size  as  cancer;  moreover,  like 
cancer,  it  is  associated  with  evident  signs  of  cachexia.  The  main 
points  of  distinction  are  the  smooth  feel  and  uniform  increase  of 
the  liver  in  waxy  disease,  its  painlessness  and  slow  progress,  its 
combination  with  enlargement  of  the  spleen  and  albuminous  urine, 
and  the  history  of  the  case  pointing  to  constitutional  syphilis, 
or  to  diseases  of  the  bones,  or  to  long-continued  suppuration, — 
in  fact,  to  the  causes  which  generally  lie  at  the  root  of  a  waxy 
or  lardaceous  state  of  organs.  In  the  differentiation  of  cases 
of  infiltrated  cancer  without  distinct  nodules,  the  physical  ex- 
ploration does  not  aid  us,  and  we  have  to  lay  stress  on  the  other 
points. 

A  fatty  liver  is  easier  to  discriminate  from  hepatic  cancer.  The 
occurrence  of  the  non-malignant  malady  in  consumptives  or  in 
drunkards,  and  the  total  absence  of  pain, — in  truth,  of  any  decided 
indications  of  hepatic  disease,  except  increased  size  of  the  organ, — 
enable  us  to  distinguish  between  the  two  affections  with  certainty. 
The  slighter  signs  of  disturbance,  both  constitutional  and  local,  the 
dissimilar  history,  and  the  uniform  enlargement  of  the  liver  sepa- 
rate chronic  congestion  from  cancer.  As  a  mark  of  distinction, 
too,  of  the  cancerous  from  all  of  these  non-malignant  disorders, 
Yirchow  lays  stress  on  the  existence  of  swollen  jugular  glands; 
and  a  small  cancerous  induration  in  the  abdominal  walls,  around 
the  umbilicus,  also  not  unfrequently  aids  the  diagnosis. 

Acute  Congestion  ;  Acute  Hepatitis  ;  Catarrhal  Jaundice. — It  is 
rarely  indeed  that  these  ailments  are  confounded  with  cancer  of  the 
liver,  because  the  history  and  the  course  the  latter  malady  takes 
are  so  dissimilar  to  those  of  an  acute  hepatic  disorder.  Yet 
there  are  cases  in  which  the  malignant  disease  is  either  developed 
with  great  rapidity,  thus  simulating  an  ordinary  acute  affection, 
or  has  lain  dormant  and  passed  unnoticed  until  it  begins  suddenly 
to  increase.  Under  such  circumstances,  even,  we  may  be  able  to 
recognize  the  malignant  complaint,  if  its  physical  phenomena  be 


624  MEDICAL   DIAGNOSIS. 

M'cll  defined;  but  if  these  be  not  elearly  marked,  the  diagnosis 
beeomes  one  of  g-reat  dittieulty. 

To  cite  a  ease  in  ilhistration  : 

A  married  woman,  twenty-five  years  of  age,  was  achnitted  into 
the  Philadelphia  Ht)spital  on  January  14,  18G2,  with  jaundiee 
and  slight  fever.  She  stated  that  she  had  been  in  excellent  health 
luitil  about  two  weeks  before,  when  she  eaught  cold  by  sleeping 
in  a  damp  apartment.  Her  appetite  and  digestion  had  been  good 
previous  to  her  present  illness,  and  she  had  been  fully  able  to 
perform  her  household  work.  Since  she  was  taken  ill  she  had 
noticed  a  feeling  of  Aveight  in  the  region  of  the  stomach  and 
liver.  Rales  indicative  of  bronchitis  were  found  in  the  chest, 
and  the  impulse  of  the  heart  was  feeble.  The  hepatic  percussion 
dulness  was  increased  in  extent,  especially  that  of  the  left  lobe ; 
but  the  outline  of  the  organ  appeared  regular  and  even.  Ten- 
derness of  the  abdomen,  more  particularly  in  the  epigastrium 
and  right  hy])ochondrium,  M'as  also  noted.  There  was  nausea, 
but  no  vomiting;  the  tongue  was  clean;  the  evacuations  were 
discolored. 

Now,  here  was  certainly  a  patient  presenting  none  of  the  signs 
of  hepatic  cancer,  except,  perhaps,  the  tenderness  over  the  en- 
larged gland.  Yet  at  the  autopsy,  which  was  made  within  a  week 
after  her  reception  into  the  hospital,  and  therefore  not  three  weeks 
from  the  apparent  beginning  of  the  complaint,  whitish  nodular 
cancerous  spots,  many  of  them  soft,  were  found  in  the  substance 
of  the  liver,  but  not  at  its  edges,  nor  forming  anywhere  distinct 
protuberances  which  could  have  been  detected  during  life. 

To  the  similarity  of  certain  cases  of  protracted  catarrhal  jaun- 
dice in  elderly  persons,  presenting  emaciation,  with  nausea,  retch- 
ing, and  vomiting,  Ave  have  above  alluded.  The  physical  signs  of 
the  enlargement  of  the  liver  may  or  may  not  assist  us,  according 
to  their  character. 

SypJiiHtic  Liver. — As  a  consequence  of  constitutional  syphilis, 
the  liver  may  at  times  exhibit  cicatrices  on  its  surface,  and  scattered 
nodules,  consisting  of  connective  tissue,  and  extending  into  the 
parenchyma.  This  condition  is  styled  syphilitic  inflammation  of 
the  liver,  or  the  syphilitic  liver.  The  organ  becomes  uneven  from 
the  contraction  of  the  cicatrized  parts,  and  is  apt  to  be  somewhat 
increased  in  size,  from  coexisting  waxy  degeneration  or  interstitial 


DISEASES    OF    THE    LIVEK.  625 

hepatitis.  The  patient  has  a  pale,  cadiectic  look,  but  is  not  jaun- 
diced,* except  from  a  temporary  catarrh  of  the  bile-ducts,  produced 
by  the  syphilitic  poison  ;  nor  is  dropsy  present,  unless  there  be  at 
the  same  time  an  affection  of  the  kidneys  or  enlargement  of  the 
spleen.  But  the  most  important  elements  in  the  diagnosis  are  the 
age  of  the  patient,  the  history  of  the  case,  and  the  detection  of 
syphilitic  cicatrices  in  the  throat.  When  contrasted  with  cancer, 
we  find,  besides  these  points,  the  chief  distinctive  marks  to  be : 
the  much  more  usual  absence  of  jaundice  and  of  dropsy,  the  not 
uncommon  increase  in  size  of  the  spleen,  the  want  of  local  hepatic 
tenderness, — unless  this  be  due  to  passing  attacks  of  perihepatitis, 
— and  the  smaller  size  and  softer  feel  of  the  nodules.  Syphilis 
of  the  liver  may  be  hereditary.f 

Affections  of  the  Gall-bladder. — Dilatation  and  cancer  of  the 
gall-bladder  are  both  very  liable  to  be  mistaken  for  cancer  of  the 
liver.  The  former  affection  may  result  from  occlusion  of  the  he- 
patic and  common  bile-ducts,  produced  by  pressure  of  surround- 
ing tumors  or  by  an  impaction  of  gall-stones ;  or  it  may  be  owing 
to  the  distention  of  the  bladder  with  an  albuminous  fluid, — the 
so-called  dropsy  of  the  gall-bladder.  In  either  instance  the  blad- 
der may  attain  an  enormous  volume,  and  give  rise  to  a  marked 
tumor  at  the  lower  margin  of  the  liver.  The  prominence  is  apt 
to  be  rounded  or  pear-shaped,  and,  except  in  those  cases  in  which 
the  occlusion  is  in  the  cystic  duct  or  at  the  neck  of  the  gall-blad- 
der, the  impediment  to  the  flow  of  bile  is  accompanied  by  intense 
jaundice  and  by  decided  hepatic  swelling.  Hence,  in  the  deep 
hue  of  the  skin,  the  uniform  enlargement  of  the  liver,  the  peculiar 
contour  of  the  prominence,  the  absence  of  ascites,  the  paroxysms 
of  pain  preceding,  not  following,  as  in  cancer  of  the  liver,  the 
other  marked  symptoms,  and  the  history  of  the  case,  which  not 
unfrequently  points  to  repeated  attacks  of  colic  from  the  passage 
of  gall-stones,  we  find  the  clue  which  permits  us  to  determine 
that  we  are  not  dealing  with  hepatic  cancer. 

*  No  jaundice  is  mentioned  in  the  cases  of  Dittrich,  Prag.  Vierteljahrschr., 
Bd.  vi.  and  vii.  ;  of  Gubler,  Memoires  de  la  Societe  de  Biologie,  tome  iv.  ; 
of  Bamberger,  Krankheiten  der  Leber,  in  Virchow,  Patbologie,  etc.  ;  or  of 
Moxon,  in  Guy's  Hospital  Eeports,  1867.  In  the  cases  of  Murchison,  Diseases 
of  the  Liver,  2d  edit.,  1877,  it  was  a  passing  or  an  absent  symptom. 

t  Arch.  Gen.  de  Med.,  June,  1884. 

40 


C2G  -MEDICAL    DIAGNOSIS. 

Cancer  of  (he  gall-bladder  is  scarcely  ever  met  with  in  young 
persons,  and  is,  as  a  rule,  associated  with  cancerous  formations  in 
the  liver  or  in  other  ortiiins.  It  is  difficult  to  make  out  a  certain 
diagnosis  of  the  alfeetion,  for  it  j)resents  a  strong  likeness  both  to 
cancer  of  the  jnloric  extremity  of  the  stomach  and  to  cancer  of  the 
liver.  From  the  latter  it  is  undistinguishable,  unless  the  situation 
and  form  of  the  tumor  be  such  that  we  can  clearly  recognize  it  as 
belonging  to  the  gall-bladder.  Sometimes  it  is  preceded  by  a  his- 
tory of  gall-stones.*  Jaundice,  as  in  cancer  of  the  liver,  may  be 
absent  or  present:  in  five  cases  reported  by  Bamberger f  it  was 
found  in  all,  and  was  even  intense.  Frerichs,  on  the  other  hand, 
states  that  in  most  instances  it  is  wanting.  MusserJ  finds  it  re- 
ported in  sixty-nine  out  of  a  hundred  cases.  In  sixty-eight  out 
of  one  htmdred  cases  analyzed  by  him  a  tumor  Avas  discovered, 
the  position  of  which  is  most  frequently  in  the  right  hypochon- 
driura  and  the  umbilical  region,  and  which  is  painful  on  pressure. 
There  is  also  generally  gradually-increasing  pain  and  a  sense  of 
weight  in  the  right  hypochondrium.  The  disease  is  more  com- 
mon in  women  than  in  men.  The  signs  of  the  cancerous  cachexia 
are  always  strongly  marked ;  as  a  rule,  more  strongly  than  in 
hepatic  cancer. 

Gall-stones  occasionally  accumulate  in  the  gall-bladder  in  such 
numbers  as  to  give  rise  to  a  hard,  even  nodulated  swelling,  -which 
may  be  mistaken  for  cancer.  But  the  tumor  is  generally  movable, 
is  not  painful  on  pressure,  and  does  not  alter  in  size,  or  does  so 
but  slowly.  Sometimes  the  patient  comjalains  of  the  feeling  of 
a  weight  rolling  from  side  to  side  when  he  turns  in  bed,  and  on 
palpation  a  crackling  sound  is  produced,  which  is  readily  dis- 
cerned A\ith  the  stethoscope.  Generally  "\ve  obtain  a  history  of 
bilious  colic.  There  may  or  may  not  be  jaundice ;  there  is  an 
absence  of  the  cachectic  symptoms  of  cancer. 

Cancer  of  the  Stomach. — This  is  discriminated  from  cancer  of 
the  liver  by  the  fiir  more  constant  vomiting,  by  the  dark  appear- 
ance of  the  ejected  matter,  by  the  more  obvious  symptoms  of  indi- 
gestion, the  persistent  pain  in  the  stomach,  or  the  pain  radiating 
from  there  to  either  hypochondrium.     Moreover,  the  seat  of  the 


*  Murchison,  op.  cit.  f  Krankheiten  des  Digestions-Apparates. 

t  Transact.  Assoc.  Amer.  Phvs.,  vol.  iv.,  1889. 


DISEASES    OF   THE    LIVER.  ■  027 

tumor  is  different ;  it  is  epigastric,  or  extending  downward,  but 
not  often  passing  into  the  right  hypochondrium,  and  it  shows 
on  percussion  a  very  different  contour  from  an  enlarged  liver. 
Yet  there  are  cases  in  which  we  are  kept  in  doubt;  especially 
those  in  which  the  left  lobe  of  the  liver  is  chiefly  affected  with  the 
cancerous  malady  and  presses  upon  the  stomach,  inducing  perhaps 
— and  thus  making  the  likeness  still  closer — obstiUate  vomiting. 
The  only  traits  of  distinction  are  then  found  in  the  presence  or 
absence  of  the  signs  of  marked  derangement  of  the  functions  of 
the  liver,  and  in  the  absence  of  hydrochloric  acid  in  the  contents 
of  the  stomach. 

Cancer  of  the  Omentum. — The  absence  of  jaundice,  and  the  un- 
altered appearance  of  the  stools,  are'  here,  too,  of  great  value  in 
indicating  that  a  tumor  near  or  joining  the  left  lobe  of  the  liver 
is  not  due  to  cancer  of  that  viscus.  Moreover,  the  boundaries  of 
the  morbid  mass  are  different  from  those  of  a  diseased  liver.  But 
we  cannot  always  trust  to  this.  Cancerous  tumors  of  the  lesser 
omentum  may  so  surround  the  liver,  and  correspond  so  closely  to 
the  regular  form  produced  by  hepatic  cancer,  that  the  two  mala- 
dies cannot  be  distinguished  ;  at  least  not  by  the  local  signs. 
Again,  a  loop  of  intestine  may  be  thrust  across  the  enlarged  liver 
at  a  point  corresponding  to  the  usual  limit  of  the  percussion  dul- 
ness  of  its  left  lobe,  thus  dividing  the  most  prominent  nodules 
from  the  greater  portion  of  the  viscus,  and  making  it  appear  as 
if  the  tumor  were  to  the  left  of,  and  below,  the  stomach,  and 
belonged,  therefore,  probably  to  the  omentum.*  In  such  cases 
we  have  to  depend  entirely  upon  the  signs  of  disturbed  liver 
function. 

Enlargement  of  the  Right  Kidney. — A  tumor  formed  by  an  en- 
largement of  the  kidney  does  not  present  the  same  outline  of  per- 
cussion dulness  as  a  cancerous  liver.  The  dulness  is,  moreover, 
bounded  by  the  tympanitic  sound  of  the  intestine,  and  is  not 
lowered  by  a  deep  inspiration  ;  and  the  signs  of  disturbed  function 
of  the  kidney,  and  an  examination  of  the  urine,  will  generally 
materially  assist  the  diagnosis.  Still,  cases  may  occasionally  hap- 
pen in  which,  owing  to  a  peculiar  shape  of  the  diseased  kidney 
and  to  the  obscurity  of  the  symptoms,  an  error  in  diagnosis  can 

*  See  case,  Proceedings  Pathological  Society  of  Phila  ,  vol.  i.  p.  275. 


()28  MEDICAL   DIAGNOSIS. 

scarcely  be  avoided.*  The  dilliculty  in  discrimination  is  height- 
ened by  the  circumstance  that  most  cases  of  morbid  groMth  of 
the  kidney,  at  least  of  one-sided  growth  sufficient  to  give  rise  to 
a  palpable  tumor,  are  cancerous,  and  are  therefore,  as  far  as  the 
manifestations  of  a  cachexia  go,  similar  to  cancer  of  the  liver. 

Finally,  in  reviewing  the  diagnosis  of  canecr  of  the  liver,  we 
must  inquire  whether  other  than  cancerous  growths,  such  as 
spindle-cell  !~ar('c)ma,  myxoma,  epithelioma,  eysto-sarcoma,  lymph- 
adenoma,  can  be  distinguished  from  true  cancer.  They  may  pro- 
duce identical  })hysical  signs  and  symptoms  ;  indeed,  a  distinction 
is  impossible,  unless  the  history  of  the  case  enable  us  to  make  it. 
Much  the  same  may  be  said  of  that  rare  disease,  tubercular  for- 
mations in  the  liver.  Leuka^mic  livers  may  attain  enormous  size, 
and  be  mistaken  for  cancer ;  and  the  cachexia  that  attends  them 
makes  the  error  more  likely.  But  the  swelling  of  the  spleen  and 
of  the  lymphatic  glands  and  the  microscopical  examination  of 
the  blood  furnish  the  points  in  diagnosis. 

Hydatids  of  the  Liver. — The  development  of  one  or  of 
several  cysts  in  the  liver,  containing  within  them  echinococci,  is 
not,  as  a  rule,  a  disorder  Avhich  occasions  serious  disturbance  of 
the  general  health.  Nor  do  the  hydatids  usually  give  rise  to 
either  jaundice,  dropsy,  or  any  marked  signs  of  gastric  or  of  in- 
testinal irritation,  or  to  fever,  or  to  local  pain.  Their  most  con- 
stant manifestations  are  a  decided  increase  of  the  size  of  the  liver, 
and  the  presence  of  elastic  tumors  discernible  in  the  hepatic  region. 
In  some  instances  xanthelasma  has  been  noticed. f  This  disorder 
of  the  skin,  however,  is  not  peculiar  to  hydatids,  but  has  been 
observed  in  connection  with  other  forms  of  hepatic  enlargement 
associated  with  chronic  jaundice. 

The  growth  of  the  hydatid  is  generally  very  slow,  and  usually 
in  one  direction  only, — upward,  downward,  laterally.  Very  com- 
monlv  the  hydatid  tumor  grows  from  the  right  lobe.  In  most 
cases  it  attains  considerable  dimensions,  and  the  liver  may  be 
found  to  encroach  upon  the  lung  as  far  as  the  second  intercostal 

*  Vidal  (Bulletin  de  la  Societe  Medicale  des  Hopitaux,  1874)  cites  errors  in 
diagnosis  between  tumors  of  the  kidneys,  especially  hydronephrosis,  and  dis- 
eases of  the  liver  attended  with  enlargement,  like  abscess  or  cancer,  made  bj' 
such  masters  in  our  art  as  Velpeau,  Nelaton,  Gosselin. 

-(-  Duckworth,  St.  Bartholomew's  Hospital  Reports,  vol.  x.,  1874. 


DISEASES    OF    THE    LIVER.  02!) 

space,  or  to  extend  far  down  into  the  abdominal  cavity.  On  per- 
cussion, the  line  of  dulness  either  of  the  upper  or  of  the  lower 
boundary  of  the  viscus,  or  of  both,  is  perceived  to  be  very  irreg- 
ular, and  occasionally  on  striking  a  series  of  abrupt  blows  on  the 
plexiineter,  or  on  the  fingers  of  the  left  hand  used  as  such,  we 
discern  a  peculiar  vibration,  similar  to  the  sensation  perceived 
on  striking  a  mass  of  jelly,  and  very  significant  of  the  existence 
of  the  cyst.  Owing  to  the  pressure  the  increasing  tumor  may 
exert  on  adjacent  structures,  we  observe  in  some  cases  dry 
cough ;  palpitation  and  displacement  of  the  heart ;  vomiting ; 
possibly  jaundice  and  ascites. 

Hydatids  ordinarily  last  for  years.  The  echinococci  may  die, 
the  sac  become  much  reduced  in  size,  or  obliterated,  and  recovery 
take  place  ;  or  the  cyst  may  discharge  its  contents  through  the 
stomach  and  intestines,  through  the  bronchial  tubes,  or  through 
the  walls  of  the  abdomen,  and  the  patient  then  gets  well.  But 
so  favorable  a  termination  cannot  be  counted  upon.  A  fatal  issue 
may  at  any  time  ensue  by  the  hydatid  tumor  bursting  into  the 
pleura  or  the  pericardium  or  the  peritoneum  and  leading  to  violent 
inflammation,  or  by  inflammation  and  suppuration  occurring  in  the 
sac,  or  in  the  tissues  immediately  surrounding  it.  Even  when  the 
hydatids  are  discharged  through  the  stomach,  intestines,  bron- 
chial tubes,  or  abdominal  parietes,  recovery  is  apt  to  be  slow ; 
nor  is  it,  indeed,  unusual  to  find  the  patient's  strength  giving  way 
before  the  contents  of  the  sac  have  been  entirely  voided  and  it 
has  closed. 

In  some  countries  hydatids  are  frequent.  In  Iceland  these 
growths  developed  from  the  eggs  of  a  tape-worm  are  so  common 
that  they  cause  one-seventh  of  the  human  mortality.  In  point 
of  diagnosis,  it  is  not  generally  difficult  to  detect  the  presence  of 
hydatids.  It  is  true  that  when  these  are  small  or  deep-seated  it 
may  be  impossible  to  discern  them.  But  a  large  and  superficially- 
seated  hydatid  tumor  can  usually  be  distinguished,  and  can  be 
separated  from  the  maladies  to  which  it  bears  a  resemblance.  It 
differs  from  an  abscess  of  the  liver  by  the  want  of  febrile  action, 
pain,  and  great  constitutional  disturbance ;  indeed,  the  latent 
character  of  the  hydatid  tumor  becomes  of  much  importance.  Its 
slow  growth,  too,  is  very  significant,  much  more  so  than  the  physi- 
cal characteristics,  which  are  here  not  to  be  trusted  to.     When,  as 


630  MEDICAL    DIAGNOSIS. 

sometimes  happens,  a  hydatid  tumor  infljuiu's  and  suppurates, 
Ave  have  nothing  to  uuide  ns  in  thi'  ditil'eri'ntial  diaiinosis  hut  the 
history  ol"  the  ease  i)revious  to  the  de\eh)pnient  of  the  urgent 
symptoms.  From  cancer  of  the  liver  we  distinoui.^h  hydatids  by 
the  absenee  of  evident  caehexia,  of  kieal  tenderness,  and  of  the 
unevenness  of  the  surface  which  the  small,  hard,  cancerous  tumors 
projecting  from  it  occasion.  On  the  other  hand,  we  have  in 
hydatid  tumor  the  sensation  on  palpation  of  elasticity  or  fluctu- 
ation. Under  rare  circumstances  this  may  happen  in  medullary 
chancer,  and  the  rapid  growth  of  the  latter  and  the  cachectic  symp- 
toms would  determine  the  diagnosis.  A  distended  gall-bladder 
may,  like  hydatid  tumor,  be  free  from  pain  on  pressure,  but, 
unlike  this,  it  is  preceded  by  attacks  of  colic,  is  generally  ac- 
companied by  deep  jaundice,  and  its  situation  corresponds  to  the 
normal  scat  of  the  gall-bladder. 

An  aneurism  of  the  aorta  differs  from  hydatids  in  the  severe — 
for  the  most  part  neuralgic — pain  the  patient  suffers,  so  utterly 
dissimilar  to  the  absence  of  pain  or  to  the  mere  feeling  of  tension 
and  weight  of  a  hydatid  swelling.  Then  the  pulsation  and  the 
other  physical  signs  aid  us.  In  aneurism  of  the  hepatic  artery, 
which  may  also  present  a  smooth,  throbbing  tumor,  we  are  apt  to 
have  deep  jaundice  from  compression  of  the  biliary  ducts. 

Pleuritic  efusions  have  many  features  in  common  with  those 
cases  of  hydatids  of  the  liver  in  which  the  growing  tumor  extends 
upward  into  the  chest.  All  the  physical  signs  of  a  large  effusion 
may  be  present,  even  the  dilatation  of  the  thorax  and  a  sense  of 
fluctuation  in  the  intercostal  spaces.  But  the  absence  of  constitu- 
tional symptoms,  the  irregular  outline  of  the  dulness  on  percus- 
sion of  the  hydatid  cyst,  the  great  displacement  of  tlie  heart,  and 
the  decided  lowering  of  the  upper  margin  of  dulness  upon  deep 
inspiration,  enable  us  commonly  to  detect  the  real  nature  of  the 
disease.  Wiien  the  cyst  has  opened  into  the  lung  and  the  hydatids 
are  being  exj)ectorated  through  the  air-passages,  the  harassing 
cough,  the  copious  sputum,  and  the  inflammation  of  the  ])ulmo- 
nary  tissue  which  is  apt  to  be  occasioned,  may  cause  the  affection 
to  be  mistaken  for  pulmonary  abscess  or  phthisis.  The  surest 
marks  of  distinction  are  furnished  by  the  changed  form  of  the 
lower  part  of  the  thorax,  and  by  finding  bile  and  the  hooks 
of  the  echinococci  in  the  sputum. 


DISEASES    OF    THE    LIVER.  631 

Renal  enlargements,  such  as  cysts,  hydronephrosis,  cancer,  are 
discriminated  from  hydatids  of  the  Hver  by  the  same  physical 
signs  by  which  we  found  them  to  be  distinguished  from  hepatic 
cancer, — chiefly  by  the  renal  tumor  having  the  tympanitic  sound 
of  the  colon  in  front  of  it,  by  not  being  affected  in  position  by 
deep  inspiration,  and  by  the  direction  of  its  growth.  Moreover, 
the  history  and  an  examination  of  the  urine  will  greatly  assist. 

Ovarian  cysts,  unlike  hydatids,  grow  from  beloNV  upward,  are 
not  influenced  by  deep  inspiration,  and  produce  enlargements 
greatest  below  and  not  above  the  umbilicus ;  then  they  have  a 
different  outline  on  percussion  from  hydatid  liver. 

But,  though  we  may  thus  generally  distinguish  hydatids  of  the 
liver  from  the  maladies  which  have  similar  symptoms,  there  are 
unquestionably  cases  in  which  it  is  extremely  difficult  to  arrive  at 
a  satisfactory  conclusion.  Under  these  circumstances,  an  explora- 
tory examination  with  an  aspirator  would  be  proper.  We  may 
at  times  detect  shreds  of  striated  hydatid  membrane,  and  portions 
of  echinococci.  Besides,  the  character  of  the  fluid  drawn  off"  will 
assist  us  materially  in  diagnosis.  It  is  as  clear  and  colorless  as 
water,  has  a  specific  gravity  of  1007  to  1011,  and  contains  not  a 
trace  of  albumen  or  of  urea,  but  large  quantities  of  chloride  of 
sodium.  No  other  fluid  in  the  human  body,  whether  in  health 
or  in  disease,  presents  these  peculiarities.* 

Occasionally  portions  of  the  liver  are  transformed  into  a  mass 
consisting  of  connective-tissue  stroma  and  numerous  large  and 
small  cells  filled  with  a  gelatinous  substance.  The  disorder  looks 
like  alveolar  carcinoma,  but  it  is  really  multilocular  hydatids  or 
echinococcus  tumors.  The  centre  of  the  mass  suppurates,  but 
even  this  does  not  diminish  the  great  resistance  of  the  hepatic 
tumor ;  nor  is  fluctuation,  save  in  the  rarest  instances,  perceptible. 
The  liver  may  retain  its  normal  shape,  or  elevations  may  be  per- 
ceptible, such  as  we  observe  in  carcinoma  and  syphiloma  of  the 
organ  :  indeed,  the  aifection  is  not  to  be  distinguished  with  any 
certainty  from  either,  except  it  be  by  the  history  and  the  attend- 
ing constitutional  symptoms.  No  jaundice  usually  accompanies 
the  hard  hepatic  swelling ;  but  in  cases  in  which  the  bile-ducts  are 
obstructed  we  meet  with  jaundice  without  dyspeptic  symptoms 

*  Murchison,  Lectures  on  Diseases  of  the  Liver,  2d  edit.,  p.  61. 


632  MEDICAL    DIAGNOSIS. 

or  previous  paroxysms  of  pain,  and  usually  without  enlargement 
of  the  gall-blatlder.  In  cases  with  icterus,  unlike  what  we  find 
in  syphilis  or  in  cancer,  there  is  complete  discoloration  of  the 
fsei'cs.* 

Let  us  now,  in  concluding  the  review  of  the  hepatic  maladies 
which  are  attended  with  decided  increase  of  the  size  of  the  orpan, 
briefly  contrast  their  most  important  manifestations.  We  have 
found  that,  as  regards  the  enlargement,  they  diifcr  materially. 
Simple  congestion,  chronic  inflammation,  fatty  liver,  do  not  attain 
nearly  the  volume  of  cancer,  of  hydatids,  of  abscess,  of  waxy 
disease  of  the  liver.  The  three  affections  first  mentioned  differ, 
moreover,  from  all  the  others,  except  the  waxy  liver,  by  present- 
ing a  uniform  and  not  an  irregularly-shaped  swelling  or  an  un- 
even outline  of  the  percussion  dulness. 

Concerning  the  symptoms,  we  observe  that,  although  these 
hepatic  disorders  all  agree  in  not  being  in  any  way  characterized 
by  jaundice,  yet  this  sign  is  more  commonly  present  and  more 
distinct  in  some  than  in  others.  In  hydatids,  and  in  the  syphilitic 
liver,  there  is  no  yellow  hue  of  the  skin  or  of  the  conjunctiva;  so, 
too,  as  a  rule,  in  waxy  liver.  In  fatty  liver  and  in  abscess  it  is,  on 
the  whole,  most  frequently  wanting.  The  same  may  perhaps  be 
said  of  cancer,  though  sometimes  there  is  decided  icterus  in  this 
malady.  In  chronic  congestion  and  in  chronic  inflammation 
we  ordinarily  find  jaundice,  though  it  may  be  but  a  slight  yellow 
tinge  of  the  skin  and  the  eye.  With  reference  to  dropsy,  we  are 
not  apt  to  encounter  it  in  any  of  the  hepatic  affections  under 
consideration  except  cancer,  and  waxy  disease,  when  more  than 
the  liver  is  implicated.  It  is  in  these  two  complaints,  also,  that 
the  most  obvious  signs  of  a  cachexia  are  met  wath  ;  while  in  ab- 
scess we  find  fever,  and  perhaps  the  greatest  constitutional  dis- 
turbance. 

As  regards  pain,  the  fatty  liver,  hydatids,  simple  hypertrophy, 
and  the  waxy  liver  are  painless ;  while,  generally  speaking,  con- 
gestion, catarrhal  inflammation  or  obstruction  of  the  bile-ducts, 
chronic  hepatitis,  intestinal  hepatitis,  hepatic  abscess,  and  cancer, 
are  more  or  less  painful  affections. 


*  See  the  cases  of  Friedreich  and  of  Niemeyer,  refen-ed  to  in  Niemeyer's 
Practice  of  Medicine. 


DISEASES    OF    THE    LIVER.  633 

Chronic  Diseases  attended  with  Decreased  Size  of  the  Liver, 
and  with  Abdominal  Dropsy. 

Cirrhosis. — A  liver  reduced  in  bulk,  very  dense  and  hard, 
exhibiting  granulations  of  various  size  separated  by  bands  of 
fibrous  tissue,  and  surrounded  by  a  thickened  serous  envelope, 
presents  the  morbid  state  known  as  cirrhosis,  or  hob-nail  liver. 
The  bands  that  result  from  the  inflammatory  thickening  of  the 
areolar  structure  of  the  liver  compress  the  vessels  and  parenchyma, 
destroying  some  of  its  secreting-cells.  The  inflammation  which 
leads  to  these  alterations  in  the  fibrous  tissue  is  generally  devel- 
oped from  a  chronic  congestion  consequent  upon  the  abuse  of 
spirituous  liquors.  But  this  cause  does  not  explain  all  eases :  in 
some,  the  malady  is  connected  with  disease  of  the  heart ;  in 
others,  with  constitutional  syphilis ;  in  others,  again,  it  cannot  be 
attributed  to  any  known  agency.  Sometimes  it  is  combined  with 
fatty  or  waxy  degeneration.  Again,  there  may  be  granular  livers 
in  which  the  fibroid  matter  preponderates  and  which  never  con- 
tract,— an  interstitial  hepatitis,  or  hypertrophic  cirrhosis.  The 
disease  is  essentially  a  disease  of  adults,  hepatic  cirrhosis  being 
very  rare  in  children.* 

In  the  first  stage  of  cirrhosis,  the  organ  is  somewhat  increased 
in  size;  then,  as'Glisson's  capsule  thickens  more  and  more,  the 
bulk  becomes  lessened.  It  is,  however,  doubtful  whether  the 
stage  of  enlargement  invariably  precedes  that  of  shrinking :  the 
process  of  reduction  constitutes  not  unfrequently  the  first  change. 
But,  without  entering  into  this  question,  we  may  state  that  there 
are  no  symptoms  by  which  we  can  recognize  the  disease  at  an 
early  period,  for  the  symptoms  at  first  are  the  same  as  those  of 
chronic  congestion, — dull  pain,  perhaps  tenderness  at  the  hypo- 
chondrium  and  pain  referred  to  the  shoulder,  disordered  diges- 
tion, and  a  sallow  or  a  jaundiced  hue  of  the  skin.  Nor  can  we 
say,  even  after  the  stage  of  contraction  is  fairly  developed,  that 
the  diagnosis  of  the  affection  is  always  possible.  It  may  rest  on 
no  stronger  grounds  than  finding  in  a  person  w^ho  is  known  to  be 
a  spirit-drinker,  "a,  tippler,"  an  intractable  ascites,  without  any 
obvious  cause  to  account  for  the  dropsy.     The  dropsy,  due  to  the 

*  See,  however,  cases  by  Howard,  Transact.  Assoc.  Amer.  Phys.,  1887. 


634  MEDICAL    DIAGNOSIS. 

obstrnetiou  of  the  portal  circ-iilation,  consists  throughoiit  most 
strikingly  of  ascites;  as  it  increases,  aHlenia  of  the  legs  niav 
be  developed,  and  passing  albuniiiniria^  from  j)rcssure  on  the 
renal  veins. 

Besides  the  dropsy,  the  dtlicr  clinical  features  of  the  malady 
are  not  very  marked.  Tlie  most  significant  signs  consist  in  the 
diminution  of  the  percussion  dulness  in  the  hepatic  region,  and 
the  detection,  by  the  touch,  of  iirin,  irregular  granulations  on  the 
margin  and  under  surface  of  the  liver.  But  both  these  signs  are 
very  difficult  to  discern,  on  account  of  the  distention  of  the  abdo- 
men with  fluid,  and  the  displacement  of  the  liver  this  may  occa- 
sion. In  fact,  it  is  often  only  after  the  performance  of  paracen- 
tesis that  the  abdominal  walls  will  permit  us  to  judge  with  any 
accuracv  of  the  shrinking  and  altered  state  of  the  organ.  This 
is  especially  true  with  reference  to  palpation ;  as  regards  percus- 
sion, it  may  be  possible,  even  when  the  abdomen  is  still  full  of 
dropsical  effusion,  to  detect  the  lessened  extent  of  the  licpatic  dul- 
ness.    In  rare  cases  cirrhosis  happens  M'ithout  abdominal  dropsy.* 

Irrespective  of  these  phenomena,  we  find  at  times  other  mani- 
festations of  disease  which  assist  us  in  the  diagnosis  of  cirrhosis. 
They  are  enlargement  of  the  spleen ;  dilatation  of  the  veins 
of  the  abdomen  :  gastric  and  intestinal  derangements  ;  hemor- 
rhoids ;  marked  loss  of  flesh  and  strength  ;  jaundice  ;  a  decidedly 
cachectic  appearance,  with  sunken  features ;  and  hemorrhages 
from  the  nose  and  mouth,  or  from  the  stomach,  or  into  inter- 
nal cavities.  The  increase  in  size  of  the  spleen  is,  however,  far 
from  constant,  and  rarely  reaches  a  considerable  extent.  The  dila- 
tation of  the  alxlominal  veins  is  not  perceived  until  an  advanced 
stage  of  the  disease,  and  is  sometimes  connected  with  a  peculiar 
vascular  net-work,  stretching  from  the  umbilicus  upward  and 
downward,  and,  as  Sappeyf  was  the  first  to  describe,  with  a 
decided  enlargement  of  the  epigastric  and  mammary  veins,  the 
blood  flowing  through  the  former  in  a  reversed  direction  from 
Avhat  it  does  in  health, — namely,  not  toward  the  liver,  but  from 
it  to  the  veins  of  the  abdominal  Avail,  and  thence  to  the  vena 
cava.     Other  external  veins  share  in  the  enlargement ;  the  veins 

*  Arch.  Gen.  de  Med.,  Nov.  1886. 

J  Bulletin  de  I'Academie  de  Medecine,  tome  xxiv. 


DISEASES    OF    THE    LIVER.  635 

of  the  legs  may  ])c  varicose,  and  the  venous  twigs  on  tlie  cheeks 
become  devehjpecl.  In  some  cases  an  irregular  but  moderate  fever 
is  also  noticed. 

Another  symptom  to  which  I  have  had  my  attention  strongly 
directed  is  the  presence  of  small  amounts  of  sugar  in  the  urine. 
Thus,  in  two  cases  which  I  saw  with  Dr.  Simpson,  Trommer's 
test  readily  detected  sugar  in  the  urine.  In  the  one  case  the 
secretion  was  scanty ;  in  the  other  it  was  abundant.  One  had 
lasted  for  several  years,  and  was  slowly  developing ;  the  other 
had  existed  about  sixteen  months,  and  waS:  rapidly  progressing. 

The  gastric  and  intestinal  derangements,  the  result  of  a  con- 
gested or  inflamed  mucous  membrane,  are  rarely  wanting :  they 
manifest  themselves  by  failing  appetite,  impaired  digestion,  both 
gastric  and  intestinal,  morning  sickness,  flatulency  and  constipa- 
tion, or  the  frequent  voiding  of  pale-colored  stools.  The  jaundice 
does  not  often  attain  a  high  degree ;  when  it  does,  it  has  a  bad 
meaning.  It  shows  itself  usually  in  a  yellowish  tinge  of  the  skin 
and  conjunctiva ;  but  in  some  cases  even  this  hue  is  absent,  and 
we  find  the  pale  skin  and  pearly  eye  of  ansemia. 

Yet  not  one  of  these  symptoms  is  really  characteristic ;  they 
become  so  only  when  viewed  in  connection  with  the  dropsy,  with 
the  local  signs  in  the  hepatic  region,  with  the  history  of  the  case, 
and  with  the  absence  of  any  organic  disease  of  the  stomach  or 
the  intestine,  which  might  explain  them.  Then  the  age  of  the 
patient,  generally  above  thirty-five  years,  and  his  habits,  must  be 
taken  into  account.  The  cirrhosis  of  young  children  is  generally 
due  to  inherited  syphilis.  Gout  seems  to  predispose  to  the  disease. 
Murchison  tells  us  that  the  condition  of  the  liver  which  develops 
gout  renders  it  liable  to  suffer  from  alcohol.  At  times  cirrhosis 
runs  a  rapid  course.* 

Another  form  of  cirrhosis,  if  it  be  a  form  and  not  a  separate 
disease,  by  comparison  rare,  has  been  mentioned, — hypertrophic 
cirrhosis,  or  "■  interstitial  hepatitis,"  or  cirrhotic  enlargement. 
Has  it  different  symptoms  or  different  causation  ?  JN'o  ;  it  has 
the  same,  and  is  undistinguishable,  except  by  the  increased  per- 
cussion dulness  it  presents,  and  by  the  signs  of  enlarged  liver 


*  Hanot,  "  Cirrhose  atrophique  a  marche  rapide,"  Arch.  Gen.  de  Med.,  June, 
1882. 


636  MEDICAL    DIAGNOSIS. 

being  usually  attended  with  more  jaundice  and  g-reater  tendency 
to  slight  febrile  attacks,  and  to  peritonitis.*  A  peculiar  mawkish 
odor  of  the  breath  has  been  spoken  of  as  present. f 

But,  with  reference  to  these  symptoms,  there  are  forms  of  hy- 
pertropliic  cirrhosis  witli  but  slight  jaundice,  without  ascites  or 
marked  development  of  the  abdominal  subcutaneous  veins,  termi- 
nating in  a  slow  cacliexia.  Generally,  however,  the  disease  begins 
witii  the  signs  of  congestion,  acute  or  chronic,  M^ith  jaundice,  and 
with  some  pain  in  the  right  hypochondrium,  and  lasts  for  years ; 
at  the  end  there  is  marked  jaundice,  and  the  patient  sinks  into 
a  tvphoid  state.  Ascites  may,  as  already  indicated,  be  wanting 
throughout,  or,  as  is  more  usual,  it  comes  on  late  in  the  malady. 
The  disease  is,  in  my  experience,  not  unfrequently  complicated 
with  a  fatty  liver,  forming  "  a  fibro-fatty  liver."  As  regards  the 
cirrhotic  state  in  the  markedly-enlarged  liver,  it  is  asserted  that 
besides  the  increase  of  fibrous  tissue,  both  within  and  without  the 
lobules,  the  smallest  biliary  ducts  are  much  developed.^ 

Cirrhosis  of  the  liver  due  to  malarial  infection  is  also  associated 
with  enlargement,  at  times  very  great.  It  presents,  moreover,  a 
persistent  chronic  jaundice,  which  may  last  for  years,  and  is  com- 
bined with  marked  enlargement  of  the  spleen  and  manifestations 
of  the  malarial  poisoning.  Bleeding  from  the  nose,  gums,  and 
intestines  is  frequent;  dropsy  and  distention  of  the  abdominal 
veins  are  absent. § 

Let  us  now  look  at  the  distinction  between  ordinary  cirrhosis 
and  some  of  the  maladies  which  resemble  it ;  and  first  let  us  com- 
pare its  traits  with  those  of  other  hepatic  affections.  From  diseases 
of  the  liver  attended  with  enlargement,  such  as  waxy  liver,  fatty 
liver,  and  chronic  congestion,  fully-developed  cirrhosis  is  discrim- 
inated by  the  presence  of  ascites  and  the  other  signs  of  seriously- 
obstructed  portal  circulation,  by  the  diminished,  or  certainly  not 
augmented,  size  of  the  organ,  and  by  the  different  history  of  the 
disorder.  From  hydatids  of  the  liver  we  diagnosticate  cirrhosis 
by  the  irregularity  of  outline  of  the  enlarged  liver  in  the  former 
complaint,  by  the  sense  of  fluctuation,  and  by  the  comparatively 

*  Hayem,  Archives  de  Physiologie,  Jan.  1874. 

t  Duckworth,  St.  Bartholomew's  Hospital  Reports,  1874. 

J  See  an  excellent  review  by  Hanot,  Arch.  Gen.  de  Med.,  Oct.  1877. 

§  Lancereaux,  quoted  in  Sajous's  Annual,  1888,  p.  335. 


DISEASES    OF   THE    LIVER.  637 

unimpaired  general  nutrition  of  the  body.  Cancer  of  tlie  liver 
is  unlike  cirrhosis  in  the  distinctness  and  size  of  the  protuber- 
ances, in  the  obvious  hepatic  enlargement,  in  the  less  marked  or 
absent  ascites,  and  in  the  normal  size  of  the  spleen.  But  when 
a  cirrhosed  liver  is  associated  with  syphilitic  nodules,  or  when  its 
volume  is  augmented  by  waxy  infiltration,  the  discrimination  from 
cancer  becomes  a  matter  of  extreme  difficulty ;  indeed,  it  may  be 
impossible  to  avoid  erroneous  conclusions.  Hypertrophic  cirrhosis 
may  also  be  very  difficult  to  distinguish  from  cancer,  except  by 
the  history  of  alcoholic  dyspepsia  and  the  enlargement  of  the 
veins,  and^  though  large  and  nodulated,  the  liver  is  rarely  so 
tender. 

We  shall  now  consider  and  compare  the  clinical  traits  of  some 
diseases  of  the  liver  producing,  like  cirrhosis,  atrophy  of  the 
organ. 

As  the  result  of  repeated  attacks  of  perihepatitis,  we  find  great 
thickening  of  the  capsule,  with  fibrous  bands  passing  into  the 
interior  of  the  organ,  and  some  atrophy.  This  condition,  de- 
scribed as  simjyle  indurcdion  of  the  liver,  is  met  with  chiefly  in  con- 
nection with  constitutional  syphilis,  though  it  is  also  seen  following 
a  right-sided  pleurisy  and  diseases  of  parts  contiguous  to  the  liver, 
producing  inflammation  which  spreads  to  it.  The  affection  is  not 
to  be  distinguished  from  true  cirrhosis,  except  by  the  causing  ele- 
ments, particularly  by  the  syphilitic  history,  and  by  the  absence 
of  the  habit  of  spirit-drinking ;  the  greater  and  more  persistent 
pain  and  tenderness  in  the  hepatic  region  are  of  significance ; 
sometimes  there  is  coexisting  heart  disease. 

In  red  atrophy,  too,  Ave  have  greatly-diminished  hepatic  dulness 
with  the  symptoms  of  portal  obstruction ;  it,  too,  is  therefore  un- 
distinguishable  from  cirrhosis  by  the  symptoms  alone,  unless  the 
difference  may  be  thought  to  consist  in  the  doubtful  points  of  far 
less  frequent  or  decided  jaundice  and  in  outbreaks  of  diarrhoea. 
But,  in  reality,  the  only  traits  of  importance  on  which  to  base  a 
diagnosis  are  that  the  dense,  reddish,  homogeneous  liver  occurs  not 
preceded  by  alcoholic  dyspepsia  or  valve  disease,  but  generally 
in  those  with  a  most  marked  history  of  malaria  or  of  dysentery 
or  of  ulceration  of  the  intestine. 

An  inflammation  of  the  portal  vein,  loith  coagida  forming  in  it, 
may  occasion  the  same  manifestations  of  deranged  abdominal  cir- 


638  MEDICAL    DIAGNOSIS, 

('Illation,  the  same  or  g-reatcr  tiimcractiou  of"  tlio  spleen  aiul  deerease 
of  the  liver,  as  cirrhosis.  And  what  emnplieatcs  the  diagnosis 
very  nineh  is,  that  eirrhosis  is  one  ot"  the  chief  diseases  which  lead 
to  obstruction  of  the  portal  vein.  Indeed,  we  cannot,  under  any 
circumstances,  positively  discriminate  this  affection  from  cirrhosis. 
Still,  wc  are  sometimes  enabled  to  distinguish  the  former  dis- 
order by  laying'  stress  on  the  much  quicker  development  of  the 
symptoms,  and  by  noting  the  rapidity  with  which  the  ascites 
returns  after  the  performance  of  the  operation  of  pai-acentesis, 
the  copious  gastric  or  intestinal  hemorrhage,  the  severe  vomiting 
and  diarrh(ra,  the  great  enlargement  of  the  abdominal  veins, 
and,  wlicn  not  too  soon  fatal,  the  marked  emaciation.  Other 
causes,  of  course,  than  inflammation  of  the  coats  of  the  vein  pro- 
duce coagula.  AVe  may  have  thrombosis  from  mere  weakness  of 
the  circulation,  or  as  the  result  of  disease  of  the  liver  structure, 
or  of  compression  by  enlarged  cancerous  or  tubercular  glands. 
The  clinical  manifestations  are  the  same  as  those  just  described. 
Compression  of  the  portal  vein  and  of  the  biliary  ducts  in  the 
fissures  of  the  liver,  in  consequence  of  the  inflammation  of  the 
areolar  tissues  surrounding  them,  may  be  separated  from  cirrhosis 
chiefly  by  the  intense  icterus  and  by  the  complete  discoloration 
of  the  stools. 

Of  non-hepatic  affections,  cirrhosis  is  most  liable  to  be  con- 
founded with  chronic  j^eiitonitis ;  a  mistake  rendered  the  more 
likely  because  chronic  congestion  or  even  chronic  inflammation 
of  the  peritoneum  may  exist  as  a  complication  of  cirrhosis.  But, 
even  when  no  such  complication  is  present,  the  diagnosis  may  be 
difficult.  It  rests  chiefly  upon  the  greater  and  more  extended 
tenderness  of  the  abdomen  in  peritonitis,  the  febrile  signs,  the 
absence  of  splenic  enlargement  and  of  dilated  veins,  the  usually 
unchanged,  or  certainly  not  jaundiced,  hue  of  the  skin,  the  asso- 
ciation with  signs  of  disease  in  other  viscera,  especially  of  the 
lungs, — for  chronic  peritonitis  is  generally  tubercular. 

Under  rare  circumstances,  cancer  of  the  stomach  may  simulate 
cirrhosis.  I  had  some  years  since  a  case  under  my  charge  at 
the  Pennsylvania  Hospital,  in  which,  with  very  slight  digestive 
symptoms,  and  without  discernible  epigastric  tumor,  considerable 
ascites  and  effusion  into  the  left  pleural  cavity  existed.  Owing 
to  this  effusion,  the  state  of  the  spleen  could  not  be  accurately 


DISEASES    OF    THE    LIVER.  639 

ascertained.  There  was  some  fulness  of  the  abdominal  veins, 
and  the  hepatic  percussion  dulness  did  not  extend  entirely  to  the 
margin  of  the  ribs.  Bile-pigment  was  present  in  the  urine,  the 
bowels  were  loose,  and  progressive  emaciation  ensued.  The  man 
had  been  very  intemperate,  and  his  case  might  certainly  have  been 
selected  as  an  illustration  of  cirrhosis ;  yet  at  the  autopsy  the 
liver,  though  small,  rather  hard,  and  deeply  congested,  was  not 
cirrhotic,  and  a  cancer  involving  the  whole  stomach,  except  the 
pylorus,  was  found.* 

Chronic  Atrophy  of  the  Liver. — Although  cirrhosis  is  the 
most  frequent  it  is  not  the  sole  cause  of  dwindling  of  the  liver. 
We  have  just  spoken  of  its  diminution  in  consequence  of  obstruc- 
tion of  the  trunk  of  the  portal  vein,  as  well  as  of  other  causes  ;  but 
besides  these  causes  we  find  some,  such  as  a  decrease  of  the  organ 
from  long-continued  closure  of  the  common  duct,  or  its  atrophy 
in  old  age,  or  in  connection  with  grave  disease  of  the  heart  or 
lungs  obstructing  the  circulation  and  causing  long-standing  hy- 
persemia  of  the  liver,  or  as  an  accompaniment  of  chronic  disease 
of  the  intestine.  The  first  of  these  morbid  states  is  mainly  dis- 
criminated by  the  deep  jaundice ;  the  second,  by  the  absence  of 
any  important  symptoms  referable  to  the  liver  and  associated 
with  the  diminished  hepatic  dulness;  the  third,  by  the  history  of 
the  case  and  the  physical  signs  of  cardiac  or  pulmonary  difficulty, 
the  more  general  dropsy,  or  at  least  by  the  oedema  of  the  legs 
preceding  the  ascites.  The  fourth  form,  partly  already  mentioned 
under  red  atrophy,  which  it  may  become,  presents  the  phenomena 
of  cirrhosis,  and  cannot  be  distinguished  from  this  unless  the  sur- 
face of  the  liver  can  be  distinctly  felt  through  the  abdominal  walls 
and  ascertained  not  to  be  irregular.  "VVe  may  sometimes  suspect 
the  cause  of  the  shrinking  of  the  organ  from  the  persistent  and 
intractable  diarrhoea  and  disturbance  of  the  stomach.  But,  on 
the  whole,  this  decrease  in  size  of  the  liver  following  gastro-enteric 
inflammation  is  not  frequent:  in  truth,  there  is  no  cause  of  simple 
atrophy  of  the  liver  so  common  as  coagulation  of  blood  in  the 
portal  vein. 

*  See,  for  a  fuller  report  of  this  case,  Proceedings  of  the  Pathological 
Society,  Amer.  Journ.  Med.  Sci.,  vol.  lii.,  1866. 


640  MEDICAL   DIAGNOSIS. 

SECTION  IV. 

ABDOMINAL   ENLARGEMENT. 

In  describing-  the  eauses  of  abdominal  enlargement,  I  shall  view 
them  as  they  occasion  a  general  and  uniform  or  a  more  circum- 
scribed and  ]iartial  swelling. 

General  Abdominal  Enlargement. 

Ascites. — The  collection  of  serous  fluid  in  the  peritoneal  sao 
gives  rise  to  dropsy  of  the  belly,  or  ascites.  This  may  form  part 
of  a  general  dropsy,  and  be  dependent  upon  an  organic  disease  of 
the  kidneys  or  the  thoracic  viscera,  or  the  accumulation  of  liquid 
mav  be  confined  to,  or  at  all  events  occupy  principally,  the  abdo- 
men. In  either  case  the  local  signs  are  much  the  same.  They 
are:  enlargement  of  the  belly;  a  dull  sound  on  percussion,  due  to 
the  presence  of  liquid;  and  the  sense  of  fluctuation  imparted  to 
the  hand  on  one  side  of  the  abdomen  by  a  wave  of  fluid  put  into 
motion  by  a  tap  on  the  other  side. 

As  regards  the  former  of  these  signs,  it  is  uniform  and  pro- 
gressive, and  is  usually  very  evident;  although,  of  course,  when 
the  quantity  of  liquid  is  small,  enlargement  of  the  abdomen  may 
escape  detection.  The  percussion  dulness  is  most  readily  perceived 
at  the  lower  portion  of  the  abdomen,  where  the  fluid  gravitates, 
unless  Avhen  prevented  from  so  doing  by  being  circumscribed  by 
peritoneal  adhesions.  The  bowels  float  usually  to  the  upper  part 
of  the  li(piid,  and  at  this  spot  their  tympanitic  resonance  may  be 
distinctly  discerned.  When  tlie  patient  is  in  the  erect  position, 
the  intestinal  percussion  note  is  commonly  discoverable  in  the 
epigastric  and  umbilical  regions.  If  he  be  placed  u})on  his  back, 
the  tympanitic  sound  is,  for  the  most  part,  found  to  extend  lower 
than  the  umbilical  region,  while  dulness  will  be  elicited  in  the 
hvpogastric  region  and  the  flanks.  If  the  person  affected  with 
ascites  be  placed  u})on  his  side,  the  flank  which  is  uppermost  be- 
comes resonant.  This  alteration  of  the  level  of  the  fluid  with 
the  change  of  position  is  thus  a  significant  sign,  and  always  hap- 
pens except  when  the  effusion  is  encysted  ;  it  is  detected  without 


ABDOMINAL    ENLARGEMENT.  641 

difficulty,  save  where  great  flatulent  distention  of"  the  bowels  or 
impaction  of  faeces  accompanies  the  accumulation  of  liquid. 

Ordinarily,  the  fluctuation  wave  felt  by  the  hand  is  easily  dis- 
cerned. It  is  obscured  by  thickening  of  the  abdominal  walls 
from  oedema,  or  from  the  accumulation  of  fat  in  the  subcutaneous 
tissues ;  it  is,  moreover,  indistinct  if  adhesions  circumscribe  the 
fluid  in  the  peritoneum.  The  amount  of  albumen  in  the  fluid 
rises  with  the  ascites  and  its  duration.  For  all  practical  applica- 
tions the  specific  gravity  determines  the  proportion  of  albumen, 
and  the  urinometer  may  be  employed  for  the  purpose.* 

There  are  no  means  of  distinguishing  the  character  of  the  fluid 
except  by  direct  observation.  It  must  be  inferred  from  the  at- 
tending symptoms.  Chyliform  ascites  has  been  not  unfrequently 
found  associated  with  tubercle.f 

The  other  symptoms  often  found  in  ascites,  such  as  a  pushing 
upward  of  the  liver,  spleen,  and  stomach,  embarrassed  breathing, 
compression  of  the  lungs,  and  digestive  disturbances,  need  not  be 
specially  described,  as  they  present  nothing  characteristic.  Nor 
is  it  necessary  to  insist  upon  the  self-evident  fact  that  a  diagnosis 
of  ascites  is  only  half  a  diagnosis,  and  that  we  should  in  every 
instance  endeavor  to  ascertain  the  cause  of  the  collection  of  fluid 
in  the  peritoneal  sac ;  and  we  may  at  once  proceed  to  consider 
the  morbid  states  with  which  dropsy  in  the  peritoneum  is  liable 
to  be  confounded.     They  are  chiefly  : 

Ovarian  Dropsy  ; 

Chronic  Peritonitis  ; 

Distention  of  the  Bladder; 

Gravid  Uterus; 

Chronic  Tympanites. 

Ovarian  Dropsy. — It  is  not  until  an  ovarian  cyst  rises  above 
the  brim  of  the  pelvis  that  it  occasions  a  swelling  marked  enough 
to  be  mistaken  for  abdominal  dropsy.  Supposing  that  it  has  led 
to  considerable  enlargement  of  the  belly,  we  are  yet  able  to  dis- 
criminate between  the  two  disorders  by  attention  to  the  physical 
signs  of  the  history  of  the  case. 


*  Kuneberg,  "  Eiweissgehalt  der  Ascitesfliissigkeiten,"  Deutsches    Archiv 
f.  Klin.  Med.,  September,  1883. 

f-Busey,  Amer.  Joui-n.  Med.  Sci.,  Dec.  1889. 

41 


642  MEDICAL    DIAGNOSIS. 

As  regards  the  former,  avc  perceive  these  cliH'erenecs  :  the  sound 
on  percussion  over  an  ovarian  cyst  is  dull  in  the  umbilical  and 
hypogastric  regions,  while  at  the  sides  the  tympanitic  resonance 
of  the  intestines  may  be  obtained.  Moreover,  when  the  patient 
assumes  different  postures  the  dulness  in  ovarian  dropsy  does 
not  change  its  position ;  and,  like  all  ovarian  tumors,  the  ovarian 
dropsy  causes  a  projection  in  the  centre  of  the  abdomen,  not  a 
flattening  there  and  a  bulging  of  the  flanks,  as  is  conuiion  in 
ascites.  In  ascites,  vaginal  and  rectal  touch  detect  fluctuation  at 
once,  and  the  uterus  is  normal  in  size,  in  position,  and  in  mobility, 
sometimes  it  is  prolapsed ;  in  ovarian  dropsy,  fluctuation  is  less 
distinct,  and  may  not  be  reached  at  all,  or  may  not  exist  in  case  of 
polycyst,  and  the  uterus  is  generally  displaced  behind  the  cyst. 
Then,  the  fluctuation  from  an  ovarian  cyst  is  apt  to  be  very  un- 
equal at  different  parts  of  the  distended  abdomen.  When  the 
effused  fluid  is  free  in  the  peritoneal  cavity,  fluctuation  may  be 
perceived  beyond  the  line  of  dulness  as  the  fluid  is  thrown  in 
waves  among  the  intestines  ;  but  when  it  is  confined  within  a  cyst, 
fluctuation  cannot  be  perceived  beyond  the  cyst-walls :  hence  the 
outline  of  the  cyst  as  obtained  by  percussion,  and  that  of  the  area 
witliin  which  fluctuation  is  perceived,  must  be  the  same.  It  should 
be  remembered,  however,  that  fluctuation  in  an  ovarian  cyst  may 
entirely  escape  detection  on  account  of  the  great  thickness  of  the 
cyst-walls>  or  the  unusual  tenseness  of  the  cyst,  even  though  it  be 
large,  or  on  account  of  the  great  density  of  the  fluid,  or  the  small 
amount  of  fluid  in  each  cyst.  In  ovarian  cyst  there  is  impairment 
of  the  general  health,  and  the  color  of  the  face  is  that  of  cachexia. 
Lastly,  the  pulsations  of  the  aorta  are  transmitted  by  an  ovarian 
tumor  to  the  anterior  surface  of  the  abdomen,  and  can  be  there 
felt  by  the  hand. 

When,  however,  there  is  ascites  complicating  an  ovarian  tumor, 
the  diagnosis  is  very  difficult.  Finding  the  fluctuation  unequal, 
and  an  irregular  outline  of  the  ovarian  growth,  may  aid  us  ;  but 
a  preliminary  tapping,  though  now  mostly  condemned  by  gynae- 
cologists, may  be  necessary  to  arrive  at  an  opinion.  According  to 
Spencer  Wells,*  entire  reliance  cannot  be  placed  on  the  chemical 
character  of  the  fluid,  since  the  rule  that  paralbumen  is  signifi- 


*  Diseases  of  the  Ovaries. 


ABDOMINAL    ENLARGEMENT.  643 

cant  of  ovarian  fluids  and  fibrin  of  serous  fluids  is  open  to  many- 
exceptions.  Spencer  Wells  *  accepts  the  presence  of  the  "  gran- 
ular cell"  detected  by  the  microscope,  as  shown  by  Drysdalc  and 
W.  L.  Atlee,t  as  characteristic  of  ovarian  fluid.  This  granular 
cell,  as  described  by  Drysdale/|  is  generally  round,  sometimes 
oval,  varies  in  diameter  from  one  five-thousandth  to  one  two- 
thousandth  of  an  inch,  is  very  elevated  and  transparent,  is  much 
smaller  and  far  less  opaque  than  the  compound  granular  cell  of 
inflammation,  and  contains  a  number  of  fine  well-defined  granules 
which  become  more  distinct  on  the  addition  of  acetic  acid,  and 
nearly  transparent  under  ether,  while  the  appearance  of  the  cell 
is  not  changed.  There  is  no  nucleus.  In  several  very  doubtful 
cases  of  abdominal  tumor  the  diagnostic  import  of  the  cell  was 
well  attested. §  The  cell  differs,  Drysdale  teaches  ns,  from  any 
other  granular  cell  found  in  the  abdominal  cavity. 

In  uncomplicated  cases,  the  history  assists  us  greatly  in  reach- 
ing a  correct  diagnosis.  In  ovarian  dropsy,  we  can,  as  a  rule, 
make  out  that  the  distention  of  the  abdomen  has  begun  at  its 
lower  portion,  and  has  gradually  spread  upward,  one  side  being 
very  much  more  prominent  than  the  other,  until  the  abdominal 
enlargement  has  become  considerable  and  the  relative  position 
of  the  umbilicus  is  altered.  Aoain,  we  do  not  find  those  siffns 
of  disease  of  the  liver,  heart,  or  kidneys  which  are  so  apt  to  co- 
exist with  ascites,  or  that  the  swelling  is  temporarily  reduced  by 
the  use  of  hydragogue  cathartics  and  diuretics,  as  in  the  latter 
disease. 

Attention  to  the  history  and  progress  of  the  complaint  is  espe- 
cially valuable  in  the  class  of  cases  in  which  the  physical  signs  are 
modified  by  the  intestines  not  being  able  to  float  to  the  surface  of 
the  fluid  in  the  peritoneal  cavity,  in  consequence  of  adhesions  to 
one  another,  or  of  a  diseased  omentum,  or  in  which  the  fluid  has 
been  limited  in  sacs  by  inflammatory  adhesions.  These  are  cases 
in  which  a  peritoneal  inflammation  has  led  to  the  effusion  of 
liquid ;  and  the  history  of  antecedent  peritonitis,  or  of  peritonitis 

*  Brit.  Med-.  Journ.,  June,  1878.  f  Ovarian  Tumors. 

+  Transactions  of  the  American  Medical  Association,  1873. 

§  See  Transactions  of  the  Patholoo;ical  Society  of  Philadelphia,  vol.  vii., 
1877;  American  Journal  of  Obstetrics,  vol.  xii.,  1879;  also  Gynaecological 
Transactions,  1883. 


644  MEDICAL   DIAGNOSIS. 

ill  connection  with  tubercular  disease,  the  pain  and  tenderness,  the 
signs  sometimes  of  a  tubercular  affection  of  the  peritoneum  and 
mesenteric. glands,  and  the  evidences  of  serious  impairment  of  the 
whole  system,  will  go  far  toward  elucidating  the  diagnosis.  On 
the  other  hand,  an  ovarian  cyst  may  contain  air,  either  from  a 
communication  with  the  intestine  or  alter  ta])ping  and  decompo- 
sition of  the  ct)ntaincd  fluid,  and  percussion  would  then  give  a 
clear  note  in  front  and  a  dull  note  below.  Under  cither  of  these 
circmnstances  physical  signs  alone  could  not  enable  us  to  make  a 
diagnosis,  and  we  should  have  to  seek  further  liiiht  from  the  his- 
tory  and  the  general  condition  of  the  patient.  This  is  especially 
true  in  the  diagnosis  between  encysted  dropsy  of  the  peritoneum 
and  an  ovarian  cyst.  If  we  obtain  by  tap])ing  a  spring-water 
fluid,  it  points  to  cyst  of  the  broad  ligament. 

Chronic  Peritonitis. — The  efi^iision  which  forms  in  consequence 
of  inflammation  of  the  peritoneum  is  commonly  spoken  of  as  one 
of  the  forms  of  ascites.  Exckiding  the  kind  of  chronic  inflam- 
mation which  is  due  to  an  attack  of  acute  peritonitis  passing  into 
a  chronic  state,  let  us  inquire  how  cases  of  chronic  peritonitis,  in 
which  the  disease  was  gradual  in  its  development,  can  be  distin- 
guished from  pure  dropsical  effusion. 

Now,  these  cases  of  chronic  peritonitis  are,  with  the  exception 
of  those  unfrequent  instances  of  chronic  diffused  peritonitis  of 
latent  origin  which  we  have  already  discussed,  almost  invariably 
associated  with  tubercle  or  with  cancer,  and  only  under  rare  con- 
ditions with  chronic  dysentery  and  dilatation  of  the  colon.  In 
tubercular  peritonitis  the  malady  generally  occurs  in  those  who 
have  at  the  same  time  tubercles  in  the  lungs  or  enlarged  caseous 
glands ;  and  when  we  find  such  patients  complaining  of  abdom- 
inal pain  and  uneasiness,  of  soreness  to  the  touch,  of  nausea  and 
vomiting,  of  diarrhoea  alternating  with  constipation,  of  having 
more  or  less  fever,  and  of  losing  flesh  and  strength;  when  we  dis- 
cover the  tender  abdomen  to  be  tense  and  much  distended,  in  part 
Math  liquid,  l)ut  especially  with  wind,  and  sometimes  very  resist- 
ant to  the  touch,  and  exhibiting  on  its  exterior  the  tracings  of  the 
convolutions  of  the  intestines ;  when  in  addition  there  is  oedema 
of  the  lower  limbs,  and  we  find  the  fever  to  be  irregular,  at  times 
high,  at  times  almost  ceasing,  and  a  growing  cachexia;  when  we 
are  able  to  exclude  as  the  cause  of  the  dropsy  disease  of  the  heart, 


ABDOMINAL    ENLAllGEMENT.  645 

disease  of  the  kidneys,  and  cii'rliosis  of  the  liver, — we  can  hardly 
be  wrong  in  presuming  the  signs  of  chronic  peritoneal  inflamma- 
tion to  be  owing  to  the  presence  of  tubercular  granulations  or  of 
tuberculous  disease  of  the  mesenteric  glands.  Even  when  the 
signs  of  disease  of  the  lungs  are  wanting,  or  are  not  well  defined, 
we  shall  generally  be  correct,  if  the  abdominal  symptoms  men- 
tioned exist,  in  determining  the  peritoneal  affection  to  be  tuber- 
cular. But  there  may  be  really  a  peritoneal  strumous  disease  with 
very  similar  symptoms.*  In  both  may  occur  a  strong  tendency 
to  inflammation  of  the  serous  membranes,  as  of  the  pleura.  In 
some  instances  the  tubercular  abdominal  disorder  develops  with 
rapidity,  and  the  disease  has  not  so  much  the  aspect  of  a  chronic 
as  of  an  acute  complaint.  The  tumefaction  and  tension  of  the 
belly  may  be  so  great  as  to  simulate  an  abdominal  tumor. f 

A  cancer  of  the  peritoneum  gives  rise  to  many  of  the  same 
phenomena  as  tuberculous  disease.  But  the  affection  is  far  less 
common,  and  there  is  this  difference  :  the  malady  usually  happens 
consecutively  to  an  external  or  an  internal  cancer,  and  scarcely 
ever  save  in  persons  advanced  in  years  ;  there  is  little  or  no  fever, 
or,  indeed,  a  subnormal  temperature ;  no  diarrhoea,  or  but  little 
diarrhoea,  and  no  profuse  sweats,  occur.  Pain,  on  the  other  hand, 
or  at  least  attacks  of  spontaneous  pain,  are  more  frequent ;  the 
lymphatic  glands  enlarge ;  and,  as  the  omentum  is  the  most 
common  seat  of  the  cancerous  growth,  we  can  generally  detect 
a  tumor  stretching  across  the  upper  portion  of  the  abdomen,  and 
extending  perhaps  from  the  epigastrium  nearly  to  the  pelvis. 
The  morbid  mass  is  unequal,  and  usually  detected  readily,  except 
where  separated  by  fluid  from  the  abdominal  parietes.  Hemor- 
rhage into  the  abdominal  cavity  or  the  effusion  of  bloody  serum 
occurs  here  as  it  does  in  tubercular  peritonitis.  In  cancerous  peri- 
tonitis the  ascitic  fluid  has  a  turbid  gray  look.  In  the  sediment 
that  forms  there  is  a  rich  cell-growth  with  manv  red  blood-cor- 
puscles.  The  cells  are  for  the  most  part  peculiar,  large  swollen 
nucleated  cells,  in  size  like  those  of  the  white  corpuscles  of  the 
blood. I     In  primary  cancer  of  the  peritoneum,  or  that  following 

*  Cases  of  Handfield  Jones,  Medical  Times  and  Gazette,  July,  1873. 
I  See  case  in  Liverpool  Hospital  Keports,  1868. 

J  Euneberg,  Deutsches  Archiv  f.  Klin.  Med.,  Sept.  1883;  also  Coe,  New 
York  Med.  Journ.,  .July, 


040  MEDICAL    DIAGNOSIS. 

cancer  of  the  retro-peritoneal  glands,  the  diagnosis  is  very  obscure, 
unless  the  tumors  arc  marked.  The  cancerous  malady  is  apt  to 
pursue  a  slowly  ])rogressive  course,  lasting  months  ;  but  it  may 
develop  as  an  acute  miliary  disease. 

Now,  it  is  not  necessary  to  jjoint  out  at  any  length  the  differ- 
ences between  these  forms  of  chronic  peritonitis  and  the  ordinary 
kind  of  dro])sy  of  the  })eritoneum.  Both  the  local  and  the  general 
symptoms  are  very  dissimilai-,  as  will  be  seen  at  once  by  contrast- 
ing the  description  just  given  with  that  of  ascites. 

Distention  of  the  Bladder. — This  may  give  rise  to  a  sense  of  fluc- 
tuation and  to  very  marked  abdominal  enlargement ;  so  marked, 
indeed,  that  patients  have  been  tapped,  under  the  supposition  that 
they  were  laboring  under  dropsy  of  the  abdomen.  But  when 
the  bladder  is  so  much  distended  as  to  simulate  ascites,  there  is 
usually  more  or  less  tenderness  on  pressure  over  the  seat  of  the 
obvious  swelling ;  which,  moreover,  presents  a  rounded  outline 
of  dulness  on  percussion.  Again,  we  have  the  history  either  of 
retention  or  of  apparent  incontinence  of  urine.*  But,  to  avoid 
all  possible  chance  of  error,  in  any  case  of  doubt  a  catheter 
should  be  introduced  into  the  bladder.  This  mode  of  procedure, 
it  may  here  be  mentioned,  is  the  one  Avhich  leads  most  speedily 
and  decisively  to  a  true  appreciation  of  the  abnormal  phenomena 
in  those  rare  cases  of  anasarca  which  are  produced  by  distention 
of  the  bladder,  and  of  which  Trousseau  has  recorded  several. 

The  Gravid  Uterus. — A  gravid  womb  is  readily  distinguished 
from  abdominal  dropsy  by  the  peculiar  form  of  the  dulness  on 
percussion,  its  steady  and  uniform  increase  corresponding  to  the 
enlargement  of  the  womb,  the  absence  of  fluctuation,  the  detection 
of  the  sounds  of  the  foetal  heart,  the  alteration  in  the  color  and 
appearance  of  the  mammary  areola,  and  the  production  of  move- 
ments in  the  womb  on  making  an  examination  per  vagi  nam. 
Very  much  the  same  signs,  too,  enable  us  to  discriminate  between 
a  gravid  uterus  and  ovarian  dropsy. 

Chronic  Tympanites. — Great  prominence  of  the  abdomen,  due 
to  flatulent  distention  of  the  bowels,  is,  if  at  all  persistent,  very 


*  In  a  case  recorded  by  Watson,  in  his  Lectures  on  the  Practice  of  Physic, 
although  the  bhidder  was  enormously  distended,  large  quantities  of  urine 
were  constantly  passing  from  the  patient. 


ABDOMINAL    ENLARGEMENT.  G47 

apt  to  be  mistaken  for  ascites.  But  the  large  alidomen  yields  not 
a  dull,  but  everywhere  a  tympanitic  sound,  and  there  is  no  fluc- 
tuation. Then  the  history  of  the  case  and  the  attending  symptoms 
throw  light  upon  the  nature  of  the  ailment. 

Besides  the  complaints  just  reviewed,  which  are  those  most  com- 
monly confounded  with  ascites,  there  are  a  few  very  rare  disorders 
which  might  be  mistaken  for  collections  of  fluid  in  the  peritoneal 
sac.  They  are :  dropsy  of  the  womb ;  dropsy  of  the  Fallopian 
tubes ;  dropsy  of  the  omentum ;  very  large  serous  cysts  in  the 
kidney ;  hydatids  of  the  liver,  of  size  so  great  as  to  lead  to  general 
abdominal  distention;  and  a  dilatation  of  the  stomach  so  exten- 
sive that  the  viscus  occupies  almost  the  whole  abdomen.  With 
reference  to  the  latter  affection,  w^e  may  distinguish  it  from  ascites 
by  the  history  of  the  case  and  the  vomiting  and  other  marked  gas- 
tric symptoms,  by  the  extended  tympanitic  percussion  note,  by  the 
indistinct  fluctuation,  which  is  not  noticed  except  over  the  most 
dependent  part  of  the  organ,  by  the  splashing  or  the  metallic 
or  amphoric  sounds  which  are  perceived  when  its  contents  are 
agitated,  and  by  the  length  to  which  the  stomach-tube  can  be  in- 
troduced. The  other  maladies  mentioned  can  be  separated  only  by 
taking  into  account  their  history  and  progress,  and  by  laying  stress 
upon  the  absence  of  those  morbid  states  which  generally  cause 
ascites,  and  upon  the  occurrence  of  special  phenomena  which  point 
to  the  structures  implicated. 

Chronic  Tympanites. — A  collection  of  gas  in  the  cavity  of 
the  peritoneum  is  of  rare  occurrence,  but  is  frequent  in  the  in- 
testinal tube,  and  the  accumulation  becomes  sometimes  a  chronic 
condition,  and  leads  to  very  great  and  uniform  enlargement  of 
the  abdomen.  We  find  this  form  of  tympanites  in  some  cases  of 
hysteria;  in  instances  of  constriction  of  portions  of  the  intestinal 
canal,  in  consequence  either  of  cicatrization,  or  of  cancer  of  the 
bowels,  or  of  their  compression  by  a  morbid  growth ;  as  a  sequel 
of  enteritis  or  peritonitis,  or  of  a  spinal  lesion ;  and  we  also 
observe  it  in  persons  whose  digestive  powers  are  weak  and  who 
partake  much  of  food — such  as  cabbages,  beans,  and  peas — which 
is  apt  to  occasion  flatulency. 

Among  soldiers  this  chronic  tympanites — owing,  perhaps,  in 
many  cases  to  the  character  of  their  diet  and  consequent  digestive 
disturbances — is  far  from  being  an  uncommon  disorder,  and  may 


648  MEDICAL   DIAGNOSIS. 

be  a  very  obstinate  one.  It  gives  rise  to  abdominal  enlargement, 
^^•hicll  is  constantly  mistaken  fur  drojisy,  bnt  which  does  not  yield 
a  sense  of  fluetuation,  or  return  on  percussion  any  other  than  a 
well-marked  tympanitic  sound.  The  distention  produces,  more- 
over, an  inability  to  take  active  exercise,  sensations  of  cutting  pain 
nnder  the  ribs,  and  palpitation  of  the  heart ;  pressure  on  the  ab- 
domen occasions  much  discomfort ;  the  soldiers,  therefore,  walk 
with  their  clothes  nnbuttoned,  and  find  it  very  irksome  to  wear 
their  belts.  They  are  sometimes  troubled  by  indigestion,  and  feel 
particularly  uncomfortable  after  meals;  or  the  symptoms  of  indi- 
gestion, although  they  may  have  been  present  at  the  beginning  of 
the  complaint,  disappear,  but  the  swelling  of  the  abdomen  persists 
for  many  months.  According  to  my  experience,  the  ailment  is 
always  gradual  in  its  development. 

Partial  Abdominal  Enlargement. 

Abdominal  Tumors. — Even  at  the  risk  of  some  repetition, 
it  is  for  clinical  purposes  a  matter  of  convenience  to  point  out 
connectedly  the  relations  an  abdominal  swelling  is  likely  to  bear 
to  the  normal  structures  of  the  abdominal  cavity,  and  to  consider, 
moreover,  the  swelling  as  constituting  the  starting-point  of  our 
diagnosis. 

Let  us  first  examine  the  meaning  of  an  abdominal  tumefaction 
occupying  solely  or  principally  one  region  of  the  abdomen. 

Right  Hypochondnnm. — The  most  usual  cause  of  a  tumor  in 
this  region  is  an  enlargement  of  the  liver,  whether  that  enlarge- 
ment be  due  to  congestion,  to  fatty  or  waxy  degeneration,  to 
chronic  hepatitis,  to  cancer,  to  hydatids,  or  to  an  abscess.  Some- 
times a  tumor  which  is  principally  in  the  lower  part  of  the  right 
hypochondrium,  or  proceeds  from  the  termination  of  this  region, 
is  simply  a  displaced  liver,  or  an  aifection  of  the  gall-bladder. 
In  the  first  instance,  the  recognition  of  the  disorder — such  as  a 
pleuritic  effusion — Avhich  has  given  rise  to  the  displacement ;  in 
the'  second,  the  history  of  the  case,  the  shape  of  the  swelling,  and 
the  symptoms  attending  it, — will  give  us  an  insight  into  its  cause. 
Again,  a  tumor  in  the  parts  mentioned  may  be  due  to  an  enlarged 
kidney,  cancerous  or  cystic,  or  especially  hydronephrosis.  Careful 
examinations  of  the  urine  and  the  history  of  the  case  furnish  the 


ABDOMINAL   ENLARGEMENT.  649 

most  certain  means  of  discrimination.  Then  we  must  also  bear  in 
mind  that  all  enlarged  kidneys  displace  the  bowel  in  a  particular 
manner ;  they  press  it  forward,  and  the  dulness  over  the  tumor  is 
largely  mixed  with  a  tympanitic  sound,  or  the  dulness  is,  indeed, 
not  very  appreciable. 

Left  Hypochondrium. — The  most  usual  tumors  in  this  region 
are  those  produced  by  enlargement  of  the  spleen.  An  increase 
in  size  of  this  viscus,  if  acute,  is  generally  owing  to  altered  blood 
conditions  and  infectious  maladies,  as  in  pyaemia,  puerperal  fever, 
acute  tuberculosis,  typhoid  fever,  relapsing  fever,  or  the  malarial 
fevers.  The  cause  of  the  swelling  is  disclosed  by  the  history  of 
the  case  and  by  the  accompanying  symptoms. 

Inflammation  of  the  spleen  is  an  affection  very  difficult  to  recog- 
nize. The  most  trustworthy  symptoms  are :  pain  in  the  left 
hypochondriura,  radiating  thence  in  various  directions,  as  far  as 
the  left  shoulder,  and  augmented  by  pressure,  especially  if  the 
serous  envelope  be  implicated,  by  coughing,  and  by  a  deep  inspi- 
ration ;  nausea  and  vomiting ;  fever  having  irregular  fits  of  exacer- 
bation ;  sometimes  delirium,  dry  cough,  and  a  sense  of  suifocation. 
The  extent  of  the  splenic  percussion  dulness  is  decidedly  increased, 
and,  when  we  are  sure  that  the  spleen  is  not  displaced,  the  sud- 
denly-widened area  of  dulness  forms  a  most  important  element  in 
the  diagnosis.  Splenitis  is  very  rarely  primary,  generally  meta- 
static. It  is  often  observed  to  be  connected  with  emboli  result- 
ing from  endocarditis,  and,  these  being  wafted  also  to  the  kidneys, 
albumen  and  blood  are  found  in  the  urine,  caused  by  the  meta- 
static inflammation.  When  suppuration  in  the  spleen  ensues,  the 
fever  may  assume  a  hectic  character  and  the  patient  lose  flesh 
rapidly,  while  the  spleen  increases  in  size.  But  there  is  no  cer- 
tainty in  these  signs,  nor,  indeed,  in  any  of  the  signs  of  splenic 
abscess  ;  this  may  be  latent  and  suddenly  rupture  into  the  abdom- 
inal cavity  or  the  stomach.  Then  there  may  be  abscesses  around 
the  spleen  with  manifestations  similar  to  those  in  its  substance  or 
to  pyo-pneumothorax.*  An  acute  enlargement  of  the  spleen  may 
also  be  owing  to  hemorrhage  into  its  substance  from  injury. 

Chronic  enlargement  of  the  spleen  may  be  caused  by  hypertrophy, 
by  waxy  disease,  by  leukaemia  and  lymphadenoma,  by  malignant 

*  Zuber,  Kevue  de  Medecine,  Nov.  1882. 


650  MEDICAL   DIAGNOSIS. 

growth,  bv  hydatids,  by  sy})hilitie  tiiiuor,  and  by  congestion  with 
subsequent  structural  changes,  such  as  occur,  for  instance,  in  mi- 
asmatic affections.  There  are  scarcely  any  symptoms  character- 
istic of  these  states,  except  the  alteration  the  blood  undergoes,  as 
evinced  by  a  markcni  diminution  of  the  red  globidcs  and  an  in- 
crease of  the  Nvhite ;  and  even  this  may  not  happen.  Waxy  hue 
of  the  face,  dropsy,  bleeding  fi'om  the  nose,  from  the  stomach, 
or  from  the  intestinal  canal,  and  digestive  disturbances,  though 
far  from  infrequent,  are  less  constant,  and  have  not  as  available 
diagnostic  value.  In  truth,  all  the  phenomena  mentioned,  except 
perhaps  the  microscopical  evidences  of  deteriorated  blood,  are,  in 
the  recognition  of  a  splenic  tumor,  of  secondary  importance  as 
compared  with  the  extended  percussion  dulness  in  the  splenic  re- 
gion. In  some  cases  the  symptoms  are  very  ill  defined,  and  death 
may  result  from  rupture  of  varices  of  the  enlarged  viscus,  without 
any  other  signs  of  a  lesion  than  those  of  increased  size  of  the 
organ.*  When  enlargement  of  the  spleen  has  reached  a  certain 
point,  the  organ  curves  into  the  hypogastric  and  right  iliac  re- 
gions, and  a  notch  or  notches  may  be  felt  on  its  anterior  and 
inner  surfaces.f  This  sign  may  be  very  valuable  in  distinguish- 
ing the  enlarged  organ  from  cancer  of  the  kidney,  for  which  it 
has  been  mistaken.^  There  is  said  to  be  a  constant  relation 
between  the  variations  of  the  volume  of  the  spleen  and  the 
variations  of  the  temperature.§ 

Having  determined  the  persistent  swelling  to  be  due  to  the  ab- 
normal size  of  the  spleen,  we  must  next  endeavor  to  ascertain  the 
cause  of  it.  The  history  of  the  case,  such  as  the  proof  of  leukae- 
mia, of  protracted  suppuration,  of  malaria,  forms,  with  the  coex- 
isting phenomena  in  other  organs,  the  main  element  in  diagnosis. 

A  fulness  projecting  from  the  left  hypochondrium  toward  the 
umbilical  or  lumbar  region  may  be  owing  to  fsecal  acmmulations 
in  the  colon.  Although  these  frecal  accumulations  do  not  occur 
so  often  in  or  near  either  hypochondrium  as  they  do  in  the  iliac 
regions,  yet  they  are  not  very  uncommon,  and  we  should  be  on 
our  guard  against  confounding  them  with  organic  disease,  whether 


*  Traube,  Yirchow's  Archiv,  1869.         f  Fagge,  Guy's  Hosp.  Kep.,  1868. 

X  Lancet,  July,  1873. 

?i  Amer.  Journ.  Med.  Sci.,  July,  1867. 


ABDOMINAL    ENLARGEMENT.  651 

of  the  stomach,  spleen,  liver,  kidneys,  peritoneum,  or  ovar)\  Their 
irregular  outline,  a  doughy  consistence  and  painlessness,  and  close 
attention  to  the  history  of  the  case  and  to  the  accompanying  dis- 
order of  the  digestive  functions,  will  generally  enable  us  to  detect 
the  true  nature  of  the  swelling.  But  we  must  not  lay  too  much 
stress  on  the  non-existence  of  constipation,  for  sometimes  great 
irritability  of  the  bowels  or  persistent  diarrhoea  is  kept  up  by  a 
large  collection  of  fsecal  matter  in  the  colon,  and  an  irritative  fever 
superadded  makes  a  strong  resemblance  to  typhoid.*  Repeated 
attacks  of  colicky  pains  and  some  soreness  to  the  touch  are  not 
unusual  in  cases  of  extensive  faecal  accumulation,  and  jaundice 
and  anaemia  have  also  been  noticed.  In  cases  of  doubt,  laxatives, 
especially  castor  oil,  should  be  employed  before  any  opinion  is 
o-iven,  and  with  the  voidino;  of  laroje  hard  fgecal  masses  the  tumor 
and  the  attending  symptoms  may  disappear. 

As  regards  swellings  of  any  kind  situated  in  either  hypochon- 
drium,  or  in  fact  at  any  portion  of  the  upper  third  of  the  abdo- 
men, it  is  always  to  be  inquired  into  whether  they  are  affected  by 
the  act  of  respiration.  This,  as  Kennedy  f  has  pointed  out,  is  a 
valuable  sign,  for  if  the  morbid  mass  move  in  consequence  of  the 
depression  of  the  diaphragm,  it  is  because  structures  are  involved, 
such  as  the  stomach  and  transverse  colon,  the  liver  or  spleen,  which 
admit  of  some  mobility ;  whereas  a  tumor  that  is  uninfluenced  must 
appertain  to  a  fixed  part, — for  instance,  to  the  aorta. 

Epigastrium. — The  most  common  cause  of  an  epigastric  tumor 
is  cancer  of  the  stomach.  The  swelling  is  then  associated  with 
the  symptoms  above  described. 

But  a  tumor  in  this  region  may  be  also  produced  by  a  disease 
of  the  pancreas.  A  swelling  produced  by  fatty  degeneration,  or 
by  uniform  simple  hardening  of  the  gland,  cannot,  as  a  rule,  be 
discerned  at  the  bedside.  In  chronic  pancreatitis,  deep-seated  epi- 
gastric pain  with  colicky  attacks,  a  large  quantity  of  matter  like 
saliva  passed  by  stool,  profuse  salivation,  sugar  in  the  urine,  fatty 
stools,  and  jaundice  have  been  observed  to  attend  the  appreciable 
swelling  extending  across  the  epigastrium.  As  regards  cancer, 
which  can  be  recognized  with  more  certainty,  the  most  trustworthy 

*  As  in  a  case  seen  with  Dr.  Arthur  V.  Meigs, 
f  Dublin  Quarterl}-  Journal,  August,  1864. 


652  MEDICAL   DIAGNOSIS. 

symptoms  arc  :  a  tumor  in  the  epigastric  region  ;  pain  there  or  in 
the  back,  not  incrcascni  by  the  taking  of  food,  but  usually  aug- 
mented by  the  erect  posture;  progressive  emaciation  and  debil- 
ity; an' appetite  capricious  rather  than  diminished,  and  in  some 
instances,  indeed,  a  i~avenous  desire  for  food  ;  constipation,  and 
at  times,  but  far  from  invariably,  fatty  stools,  or  fat-crystals  in 
abundance  in  the  grayish  stools.*  Besides  these  indications,  we 
commonly  find,  as  the  disease  advances,  obstinate  jaundice  and 
occasional  vomiting.  Many  of  these  phenomena  belong  also  to 
cancer  of  the  stomach  ;  in  truth,  we  never  can  be  certain  of  the 
existence  of  the  pancreatic  malady  until  we  have  excluded  the 
gastric  affection.  In  a  differential  diagnosis  of  this  kind,  the 
early  presence  and  habitual  occurrence  of  vomiting  after  meals, 
the  sour  eructations,  the  hsematemesis,  the  absence  of  free  hydro- 
chloric acid  in  the  stomach-contents,  and  the  absence  of  jaundice, 
assist  us  in  locating  the  seat  of  the  disease  in  the  stomach.  Cal- 
culous disease  of  the  pancreas  is  a  very  rare  affection.  There  are, 
in  addition  to  the  dull  sense  of  weight  at  the  epigastrium  and 
other  symptoms  of  pancreatic  disease, — such  as  sugar  in  the  urine, 
vomiting,  fatty  stools, — sharp,  irregular  attacks  of  paroxysmal 
pain,  due  to  the  passage  of  calculi.  In  cases  of  large  concretions 
these  attacks  of  colic  may  become  associated  with  jaundice. f 

An  epigastric  tumor  is  sometimes  simulated  by  a  contraction 
of  the  ujjper  portion  of  the  rectus  muscle  on  palpation ;  but  the 
swelling  soon  subsides,  especially  if  rubbed.  Occasionally,  how- 
ever, a  tumefaction  due  to  contraction  of  an  abdominal  muscle 
may  be  of  some  duration.^  I  have  known  a  contraction  of  the 
rectus  muscle  in  a  case  of  gastric  cancer  occasion  so  obvious  a 
resistance  and  swelling  that  it  was  looked  upon  as  due  to  ma- 
lignant disease  of  the  intestine  or  of  the  peritoneum.  More- 
over, the  rigid  muscle  gave  rise  to  dulness  on  percussion.  But, 
though  the  phenomena  were  for  a  long  period  a  marked  feature 
of  the  case,  it  was   observable  that  the  muscle  was  raised  and 

*  But  collections  of  fat-crystals,  Gerhardt  has  found,  are  also  detected  in  the 
pale  stools  of  icterus  without  pancreatic  disease :  when  the  bile  reappears  in  the 
stools  the  crystals  are  no  longer  seen. 

f  Pepper,  Medical  News,  Dec.  25,  1882;  and  Johnston,  Amer.  Journ.  Med. 
Sci.,  Oct.  1883  ;  see  also  eighteen  collected  cases  in  Sajous's  Annual,  1889,  C.  44. 

J  Greenhow's  cases,  Lancet,  1857. 


ABDOMINAL    ENLARGEMENT.  653 

rigid  to  a  decided  degree  only  in  certain  positions ;  at  all  events, 
that  certain  positions  gave  a  distinct  outline  to  the  swelling,  and 
that  the  latter  then,  like  the  line  of  dulness,  was  regular  and 
straight,  evidently  corresponding  to  the  contour  of  the  muscle. 
And  this  occurs  in  all  instances  of  contraction  of  the  rectus,  no 
matter  with  what  associated. 

The  muscular  contractions  are  not  always  confined  to  one 
muscle,  or  to  the  whole  of  one  muscle,  and  when  irregular,  and 
particularly  when  associated  with  tympanitic  distention  of  the 
intestine,  give  rise  to  most  of  the  so-called  "phantom  tumors" 
of  the  abdomen.  These  swellings  are  perplexing,  and  are  con- 
stantly mistaken  for  serious  abdominal  tumors.  The  history  of 
the  case,  the  absence  of  grave  constitutional  symptoms,  the  most 
frequent  occurrence  of  the  tumefaction  in  females,  especially  in 
hysterical  females,  and  the  usually  coexisting  constipation,  furnish 
us  with  valuable  signs  of  distinction.  But  I  believe  the  use  of 
angesthetics  to  be  the  most  important  means  of  diagnosis.  I  was 
first  led  to  employ  them  a  number  of  years  ago,  in  a  case  which 
had  baffled  the  skill  of  several  eminent  surgeons,  one  of  whom 
had  proposed  to  the  patient  an  operation  as  the  only  means  of 
relief  from  what  was  considered  an  ovarian  disease.  The  patient 
was  thirty-one  years  of  age,  a  widow,  and  evidently  of  highly  hys- 
terical temperament.  She  was  very  subject  to  constipation  ;  and 
the  swelling  of  which  she  complained  was  of  irregular  outline 
and  occupied  the  centre  of  the  abdomen,  extending  some  distance 
on  each  side  of  the  median  line.  It  was  hard  and  resisting  to 
the  touch,  but,  on  strong  percussion,  yielded  a  tympanitic  sound. 
Whenever  it  was  touched  she  shrank.  Thorough  relaxation  was 
produced  by  the  administration  of  ether ;  the  hand  could  be 
pressed  almost  against  the  vertebral  column,  and  all  signs  of  the 
tumor  disappeared.  A  complete  recovery  took  place ;  and  thus 
terminated  a  case  which  had  lasted  for  fully  one  year,  and  in 
which  it  is  highly  probable,  from  the  fact  that  the  patient  was 
fond  of  having  her  urine  drawn  off  by  the  catheter,  and  had 
shown  other  manifestations  of  a  similar  type  of  hysteria,  that  the 
swelling  was,  in  part  at  least,  artificially  produced.  But  in  any  of 
the  phantom  tumors  I  would  recommend  the  use  of  anaesthetics 
for  purposes  of  diagnosis ;  nay,  they  may  be  most  advantageously 
employed,  for  similar  reasons,  in  all  cases  of  abdominal  swelling 


654  •     MEDTCAI.    DIAGNOSIS. 

in  which  the  rigid  state  of  the  alnloniinal   walls  interferes  with 
acciiraey  of  investigation. 

In  soldiers  we  at  times  observe  one  or  several  small  movable 
tnmors,  yielding  a  tympanitic  sonnd  on  percnssion,  in  the  epigas- 
tric or  at  the  npper  part  of  the  umbilical  region.  They  are, 
probably,  small  portions  of  intestine  \\hicli  have  been  pushed 
between  the  fasciculi  of  a  ruptured  rectus  muscle,  similar  to 
umbilical  hernia. 

Umbilical  Region. — Tumors  which  are  found  in  this  region  form, 
as  a  rule,  merely  portions  of  a  swelling  that  is  princijially  seated 
in  the  epigastrium  or  in  the  hypochondria,  such  as  cancer  of  the 
stomach,  of  the  liver,  of  the  pancreas,  or  of  the  omentum,  and 
dilatation  of  the  gall-bladder.  The  only  two  affections  which  are 
apt  to  occasion  a  swelling  solely,  or  at  least  principally,  limited 
to  and  perceptible  in  the  umbilical  region,  are  tuberculous  disease 
of  the  mesenteric  glands  and  a  movable  kidney. 

The  symptoms  of  the  former  malady,  or  tabes  mescnterica,  are 
much  the  same  as  those  of  tubercular  peritonitis.  Indeed,  unless 
the  enlarged  mesenteric  glands  can  be  felt  through  the  abdom- 
inal parietes,  the  discrimination  is  uncertain.  The  abdomen  is 
prematurely  large,  is  slightly  tender  on  pressure,  and  has  often  a 
doughy  feel ;  the  child — for  it  is  almost  exclusively  in  children 
that  the  disease  is  seen — loses  flesh,  the  digestion  is  impaired,  the 
evacuations  are  frequent  and  unhealthy.  It  often  jjresents  signs 
of  scrofulous  disease  elsewhere ;  and  under  such  circumstances  we 
cannot  be  at  a  loss  in  determining  the  nature  of  the  tumefaction 
in  the  umbilical  region.  The  simulation  of  the  disease  in  adults, 
especially  in  young  women,  by  pseudo  tabes  mesenterica,  has  been 
described  in  reviewing  the  affections  of  the  stomach. 

"When  the  kidneys  are  not  firmly  held  by  their  attachments,  they 
become  displaced,  and  are  apt  to  give  rise  to  serious  errors  in  diag- 
nosis. The  dislocated  organ  is  perceived  under  the  margin  of  the 
ribs  on  the  right  flank,  or  in  the  umbilical  region,  and  sometimes 
extends  across  the  median  line.  The  mass  is  easily  moved,  may 
be,  by  careful  and  methodical  pressure,  returned  to  the  renal  region, 
and  presents,  on  palpation  and  on  percussion,  the  outline  of  the 
kidney.  The  lumbar  region  yields  a  tympanitic  sound  on  percus- 
sion, and  we  find  less  resistance  and  a  slight  depression  over  the 
usual  seat  of  the  organ,  which  depression  is  effaced  by  pressing 


ABDOMINAL    ENLARGEMENT.  655 

the  tumor  into  the  lumbar  region.  There  is  in  some  instances 
sensitiveness  over  the  displaced  organ,  especially  after  fatigue,  or 
a  blow,  or  strong  pressure ;  and  pressure  in  examining  the  part 
gives  rise  to  the  same  sensation  as  when  the  renal  region  of  the 
non-aifected  side  is  pressed  ;  but  we  never  find  any  disturbance  of 
the  urinary  functions,  nor,  in  fact,  except  a  disagreeable  feeling  in 
walking,  does  any  real  inconvenience  result  from  the  accident,  save 
in  tliose  cases  in  which  the  movable  kidney  has  become  painful, 
or,  by  compressing  the  vena  cava  or  portal  veins,  occasions  dropsy. 
The  disorder  is  most  apt  to  occur  after  violent  exertion,  or  after 
many  pregnancies,  or  may  be  due  to  attacks  of  congestion  of  the 
organ.  The  right  kidney  is  oftener  movable  than  the  left. 
Women  are  more  liable  to  displacements  of  the  organ  than  men, 
partly  in  consequence  of  lacing ;  and  there  seems  to  be  a  special 
connection  between  the  disorder  and  hysteria,*  and  gastric  dilata- 
tion, and  membranous  enteritis. 

The  affection  may,  of  course,  be  mistaken  for  any  form  of 
abdominal  tumor,  and  if  the  kidney  should  have  become  ad- 
herent the  diagnosis  is  uncertain.  Generally  the  disorder  can 
be  distinguished  by  the  absence  of  signs  of  constitutional  disturb- 
ance ;  by  the  history  of  the  case ;  and  by  the  physical  phenomena 
mentioned.  To  these  may  be  added  the  comparatively  slight  dul- 
ness  or  rather  the  tympanitic  character  of  sound  elicited,  except 
on  very  strong  percussion,  over  the  seat  of  the  tumor.  This  is 
an  important  fact  as  regards  the  discrimination  of  a  movable  and 
displaced  spleen,  in  which,  as  the  organ  is  generally  enlarged,  there 
is  considerable  and  extended  dulness  on  percussion.  Moreover, 
the  history  of  the  splenic  disorder,  which  not  uncommonly  can  be 
traced  to  a  malarial  affection,  the  usually  great  tenderness,  the 
nausea,  dyspeptic  symptoms,  and  hemorrhagic  tendencies  which 
attend  the  displacement  of  the  spleen,  and  the  notch  which  can  be 
felt  in  it,  will  assist  us  in  our  diagnosis. f 

Yet  another  of  the  abdominal  organs  is  occasionally  displaced 

*  Schmidt's  Jahrb.,  No.  2,  187L 

t  Cases  of  displaced  spleen  are  recorded  by  Dietl,  Wiener  Med.  Wochen- 
schrift,  No.  23,  1856,  also  in  Archives  Generales,  1858,  tome  ii.  ;  Eoki- 
tansky,  quoted  in  Brit,  and  For.  Med.-Chir.  Rev.,  Oct.  1860;  see,  too,  Clarke, 
Dubl.  Hosp.  Gaz.,  Aug.  1860;  Med.  Times  and  Gaz.,  Nov.  1869;  and  G.  Engel, 
Centralbl.  f.  Gyniik.,  Leipz.,  1886,  x. 


656  MEDICAL   DIAGNOSIS. 

and  movable, — the  liver.  Now,  a  movable  liver  won  Id  be  often 
mistaken  for  a  movable  si)leen,  were  it  a  more  common  aftcc- 
tion.  But  very  few  well-authentieated  cases  are  on  record.*  In 
these  the  peritoneal  attachment  of  the  organ  had  become  lax, 
usually  in  consequence  of  pregnancy ;  in  the  hc})atic  region  there 
was  a  tympanitic  sound  on  percussion ;  and  in  the  umbilical  re- 
gion and  toward  the  right  flank  a  solid  body  was  discerned,  the 
u})pcr  border  of  wliii-h  presented  a  convex  outline,  the  lower  bor- 
der was  in  the  inguinal  region.  The  displaced  organ  was  easily 
pushed  about,  and  could  be  replaced  in  its  proper  situation.  The 
spleen  was  found  in  its  usual  seat ;  the  symptoms  were  merely 
those  of  weight  and  uneasiness  in  the  abdomen.  The  movable  or 
wandering  organ  may  be  painful  or  painless.  It  has  the  physical 
characters  of  the  liver,  and  the  most  certain  sign  is  the  detection, 
on  palpation,  of  the  notch  between  the  right  and  the  left  lobe  and 
of  a  zone  of  tympanitic  resonance  between  the  swelling  and  the 
lung.  The  diagnosis  is,  however,  always  difficult  and  doubtful. 
New  growths  of  the  kidney,  as  a  case  of  Legg's  proves,  are  par- 
ticularly confusing.  In  most  recorded  cases  autopsies  are  want- 
ing ;  and  the  whole  subject  is  very  obscure.  The  aifection  is  more 
usual  in  women  than  in  men,  and,  besides  pregnancy,  tight  lacing 
and  chronic  inflammation  of  the  peritoneum  are  said  to  lead  to  it. 
Lumbar  Region. — Tumors  in  this  region,  or  on  either  flank,  are 
occasioned  by  some  morbid  growth  of  the  kidney,  or  by  an  abscess 
in  it  or  its  surroundings,  or  in  the  psoas  muscles.  Again,  they  may 
be  due  to  fascal  accumulations  ;  or,  if  on  the  right  side,  to  very  con- 
siderable increase  of  the  liver ;  if  on  the  left,  to  a  greatly-enlarged 
spleen.  To  discriminate  between  these  conditions,  we  have  to 
determine  whether  the  swelling  fluctuates  or  not;  w^e  must  also 
analvze  the  urine,  and  inquire  minutely  into  the  circumstances 
preceding  and  attending  the  tumefaction.  It  is  thus  only  that  we 
can  attain  the  necessary  data  for  a  diagnosis,  which  has,  indeed, 
often  to  be  reached  by  the  process  of  exclusion. 

*  See  Cantani,  Ann.  TJnivei-s  di  Medicina,  1866  ;  and  Meissncr's  article  in 
Schmidt's  Jahrb.,  1869,  No.  1;  also  ib.,  No.  2,  1871;  Blet,  Le  Foie  mobile, 
These  de  Paris,  1876 ;  Legg,  St.  Bartholomew's  Hospital  Eeports,  1877  ;  Arini, 
Anales  del  Circulo  Med.  Argentine,  quoted  in  Amer.  Journ.  Med.  Sci.,  July, 
1884;  H.  W.  Seager,  Brit.  Med.  .Journ.,  Lond.,  1885,  ii.  ;  L.  Landau,  Deutsche 
Med.  Wochenschr.,  Berlin,  1885,  ii. 


ABDOMINAL.  ENLAEGEMENT.  657 

Tumors  behind  the  peritoneum  may  give  rise  to  a  visible  promi- 
nence in  either  himbar  region,  extending  to  the  upper  part  of  the 
iliac  region.  The  most  common  cause  of  these  tumors  is  cancer 
of  the  lymphatic  glands  lying  by  the  sides  or  in  front  of  the  ver- 
tebral column.  The  disease  is  very  difficult  of  detection.  Still, 
we  may  suspect  its  existence  if,  in  a  patient  who  is  evidently 
cachectic,  and  who  is  steadily  losing  flesh  and  strength,  we  dis- 
cover, on  deep  palpation  on  one  side  of  the  linea  alba  or  in  the 
flank,  a  tumor  which,  owing  to  its  being  surrounded  by  intestine, 
returns  a  tympanitic  percussion  sound.  In  some  cases  the  swell- 
inof  communicates  the  beat  of  the  aorta  and  simulates  an  aneu- 
rism,  or  it  presses  on  the  vena  cava  and  gives  rise  to  enlargement 
of  the  abdominal  veins  and  of  those  of  the  lower  extremities,  and 
to  oedema  of  the  legs.  The  disease  may  involve  the  iliac  glands 
and  the  tumor  extend  into  the  pelvis,  or  it  may  reach  upward  to 
the  diaphragm ;  and,  by  the  cancer  spreading  to  the  posterior  me- 
diastinum, it  may  finally  open  the  aorta,  producing  hemorrhages 
precisely  like  those  coming  from  an  aneurismal  sac* 

Iliac  Regions. — Tumors  in  either  of  these  regions  may  be  due  to 
many  different  causes.  They  are,  as  we  have  elsewhere  discussed, 
principally  owing  to  ovarian  affections ;  to  fsecal  accumulations ; 
to  disease  of  the  large  intestine,  such  as  intussusception  or  cancer ; 
and  to  pelvic  abscess.  Sometimes  they  are  caused  by  displacement 
of  the  kidney,  by  enlargement  of  the  spleen,  and  in  women  by 
retro-uterine  hsematocele,  or  by  extra-uterine  pregnancy. 

The  ovarian  tumors  are,  as  a  rule,  distinguished  from  the  other 
disorders  mentioned  by  their  more  or  less  globular  form,  by  their 
movability  from  side  to  side  or  in  an  upward  direction,  by  their 
seeming  to  spring  out  of  the  pelvis,  and  their  evident  attachment 
below,  by  the  displacement  of  the  womb,  by  the  comparatively 
unimpaired  general  health,  and  by  their  indolent  and  generally 
painless  nature.  These  remarks  do  not  apply  to  the  very  slight 
swelling  occasioned  by  ovarian  inflammation,  for  here  the  tumid 
spot  is  often  the  seat  of  severe  pain.  The  healthy  ovary  is  not 
sensitive  to  the  touch.  To  examine  the  ovary  with  exactness, 
the  abdominal  muscles  must  be  completely  relaxed  ;  the  patient  is 
placed  in  the  attitude  recommended  by  Marion  Sims, — on  her 


*  Case  reported  by  Haldane,  Edinburgh  Medical  Journal,  Aug.  1868. 

42 


G58  MEDICAL    DIAGNOSIS. 

back,  with  tlic  shouklers  suj)p()rtetl,  tlu'  k\i2;.^  drawn  up  so  that  the 
lioels  are  a  few  inehes  asiuukT  and  the  tliiii'li.s  kill  easily  apart. 

As  ovarian  tumors  grow  and  spread  ui)ward  they  give  rise  to 
diffieulties  in  diagnosis,  whicli  we  have  already  examined  into. 
We  may  here  again  mention  the  manner  in  whieh  ovarian  may 
simulate  renal  growths.  Si)encer  Wells  dwells  particularly  on  the 
absenee  of  fluetuation  in  the  vast  majority  of  instances  of  en- 
larged kidney ;  on  the  renal  tumor  being  first  detected  between 
the  false  ribs  and  the  ilium  ;  on  the  signs  in  the  urine,  and  on 
the  absence  of  those  changes  in  the  quantity  and  regularity  of  the 
menstrual  discharges  which  are  common  in  ovarian  disorders. 
Moreover,  the  ovarian  growth-  usually  displaces  the  intestine 
backward ;  in  the  renal  groAvth  it  is  pressed  forward  ;  and  large 
tumors  of  the  right  kidney  ordinarily  have  the  ascending  colon 
on  their  inner  border,  while  tumors  of  the  left  kidney  are  gener- 
ally crossed  from  above  downward  by  the  descending  colon. 

Among  the  causes  of  a  tumor  in  either  iliac  fossa,  reiro-ntenne 
hsematocele  has  been  mentioned.  The  tumor,  commonly  of  rounded 
shape,  rises  above  the  brim  of  the  pelvis,  but  is  traceable  into  it. 
It  forms  quickly,  and  an  examination  through  the  vagina  detects 
an  elastic  mass  and  at  times  the  grating  of  the  blood  coagula; 
faintness  and  collapse  attend  its  production.  ISIuch  the  same 
physical  phenomena  are  presented  by  the  swelling  due  to  pelvic 
cellulitis.  But  the  slow  way  in  which  the  tumor  forms,  the  pres- 
ence of  that  hot,  puffy,  thickened,  brawn-like  condition  of  the 
vaginal  wall,  so  dwelt  upon  by  Simpson,  the  usually  greater  ten- 
derness of  the  swelling  felt  through  the  walls  of  the  vagina,  and 
the  feverishness  and  constitutional  symptoms  attending  the  gradual 
formation  of  the  abscess,  are  distinguishing  marks,  except  where 
the  contents  of  the  htematocele  suppurate,  when  for  a  differential 
diagnosis  we  may  have  to  rely  on  the  history  of  the  case. 

Hypogastric  Region. — Distention  of  the  bladder  and  enlarge- 
ment of  the  uterus,  whether  produced  by  air,  by  liquid,  by  a 
morbid  growth,  or  by  pregnancy,  are  the  most  usual  sources  of  a 
swelling  in  this  region.  If  due  to  any  one  of  these  causes,  the 
outline  of  the  tumor  is  regular  and  rounded  ;  and  by  the  aid  of 
the  catheter,  of  explorations  through  the  vagina  and  the  rectum, 
and  of  the  history  of  the  case  and  the  attending  symptoms,  we 
are  generally  enabled  to  arrive  at  a  correct  diagnosis. 


ABDOMINAL  ENLARGEMENT.  659 

A  tumor  in  the  hypogastriiim  may  also  have  its  origin  in 
splenic  enlargement,  in  diseases  of  the  peritoneum,  or  in  hajma- 
tocele.  In  the  latter  case  it  is  apt  to  be  uniform  and  to  extend 
to  the  iliac  fossae. 

In  concluding  this  sketch  of  abdominal  tumors,  we  shall  briefly 
glance  at  those  which  are  likely  to  occupy  more  than  one  region, 
and  sometimes  even  the  whole  or  the  greater  part,  of  the  abdomen. 
In  rare  instances,  a  cancer  of  the  liver,  or  hydatids  of  that  organ, 
or  a  fibrous  tumor  of  the  uterus,  or  a  solid  ovarian  growth,  or 
an  enlarged  spleen,*  or  a  kidney  the  pelvis  of  which  has  become 
enormously  distended  in  consequence  of  obstruction  of  the  ureter, 
may  lead  to  the  formation  of  a  swelling  which  occupies  nearly 
the  entire  abdomen.  But  the  most  usual  cause  of  so  diffuse  a 
tumor  is  carcinoma  of  the  peritoneum. 

This  affection,  when  very  extensive,  may  give  rise  to  a  uniform 
swelling  stretching  across  the  abdomen,  and  equally  marked  on  both 
sides  of  the  median  line,  or  to  several  small  tumors,  which  are 
evidently  unconnected  with  any  organ  beneath.  It  is,  moreover, 
apt  to  occasion  a  peritoneal  friction  sound,  to  exhibit  a  varying 
resistance  to  pressure  at  different  points,  to  lead  'to  ascites,  to  loss 
of  flesh  and  appetite,  and  chiefly,  by  the  peritonitis  it  sets  up,  to 
the  occurrence  of  fever.  Much  the  same  symptoms  may  be  pro- 
duced by  hydatid  disease  of  the  peritoneum,  though  here  there  is 
less  fever,  the  swelling  may  be  uniform  or  even  more  irregular, 
the  abdominal  enlargement  greater  and  painless,  and  we  may 
be  able  to  detect  the  hydatid  fremitus  and  the  booklets  in  the 
evacuated  fluid. f  Yet  as  regards  the  hydatid  thrill  we  must 
bear  in  mind  that  a  similar  sensation  is  obtained  from  large 
parovarian  cysts  i  or  from  colloid  cancer  of  the  peritoneum,  a 
sensation  of  peculiar  and  very  superficial  fluctuation,!  associated, 
however,  here  with  grave  symptoms  of  cachexia,  and  generally 
with  a  rapidly-spreading  growth.     Peritoneal  abscesses  enclosed 

*'As  in  the  case  reported  by  Porter,  Philadelphia  Medical  Times,  June, 
1875,  in  which  the  spleen  weighed  twenty-one  pounds. 

t  See  the  cases  of  Bright,  in  Clinical  Memoirs  on  Abdominal  Tumors,  re- 
published from  Guy's  Hospital  Keports  by  the  New  Sydenham  Society. 

X  Bristowe,  St.  Thomas's  Hospital  Keports,  vol.  xi. 

^  As  in  the  instances  recorded  by  Albert  Eobin,  Bull,  de  la  Soc.  Anat., 
1873,  and  Vidal,  Bull   et  Mem.  Soc.  Med.  des  Hopit.,  1874. 


660  MEDICAL    DIAGNOSIS. 

by  adhesions  will  also,  if  large,  give  rise  to  sevieral  of  the  signs 
of  a  cancer ;  but  the  history  of  an  antecedent  local  or  general 
peritonitis,  the  swelling  not  being  influenced  by  changes  in  the 
posture  of  the  patient  or  by  the  acts  of  respiration,  the  indistinct 
fluctuation  of  the  tumefaction,  and  its  acute  course,  will  ordinarily 
enable  us  to  distinguish  the  non-malignant  from  the  malignant 
aifection.  In  mre  instances  the  tumor  may  be  enormous,  increase 
rapidly,  yet  be  simply  fatty.  There  are  no  means  of  positively 
distinguishing  the  affection.*  Harcoma  cannot  be  told  from  car- 
cinoma ;  it  is  more  common  in  advanced  age. 

In  some  cases  the  malignant  disease  is  closely  simulated  by 
dilatation  of  the  colon,  caused  ordinarily  by  facal  tumors.  This, 
though  it  may  present  but  a  single  swelling,  generally  occasions 
several,  which  are  commonly  seated  at  the  middle  third  of  the  ab- 
domen, are  apt  to  appear  on  both  sides,  to  be  movable  and  painless 
and  to  bear  handling  without  pain,  to  change  their  position  slightly 
at  intervals,  and  to  become  occasionally  less  in  size.  Then,  after 
the  case  has  been  for  some  time  under  observation,  we  may  be 
able  to  notice  large  and  characteristic  discharges ;  though  we 
must  not  forget  that  a  mere  sluggish  state  of  the  bowels,  or  even 
diarrhoea,  may  exist  while  the  colon  is  dilated  and  perhaps  filled 
with  faecal  accumulations.f  Sometimes  the  mass  may  be  seated 
above  the  symphysis  and  be  mistaken  for  a  pelvic  tumor.  Like 
a  cancerous  growth,  it  may  in  time  occasion  occlusion  of  the 
intestine  and  the  signs  of  complete  intestinal  obstruction. 

Cancer  of  the  intestine  has  symptoms  similar  both  to  faecal  accu- 
mulation and  to  cancer  of  the  peritoneum.  The  marked  cachexia 
and  the  signs  of  persistent  and  increasing  narrowing  of  the  bowel, 
as  shown  by  the  flattened  faeces,  the  blood  and  pus  in  the  stools,  the 
frequent  attacks  of  colicky  pains,  and  the  vomiting,  distinguish  it 
from  the  former  affection,  with  Avhich,  moreover,  it  may  be  tem- 
porarily combined.  The  limitation  of  the  swelling,  the  absence 
of  dropsy,  the  character  of  the  stools,  the  frequent  change  in  the 
position  of  the  tumor  and  in  its  distinctness, J  and,  if  it  affect  the 
duodenum,  the  decided  jaundice,  separate  it  from  peritoneal  cancer. 


*  See  St.  George's  Hospital  Reports,    vol.  v.,  1870,  p.  2-j3. 

■(•  For  several  interesting  cases  of  the  disorder,  see  Kennedy,  loc.  cit. 

X  Leube,  Ziemssen's  Cyclopaedia. 


ABDOMINAL   PULSATION.  661 

SECTION   V. 

ABDOMINAL    PULSATION. 

Aortic  Pulsation. — By  far  the  most  frequent  cause  of  a 
pulsation  visible  in  the  abdomen,  and  especially  at  the  epigastric 
region,  is  a  throbbing  of  the  abdominal  aorta.  It  is  common  in 
hysterical  persons.  Some  women  are  liable  to  it  immediately  be- 
fore their  menstrual  periods  or  during  the  earlier  months  of  preg- 
nancy. In  men  it  is  most  often  seen  in  those  who  suifer  from 
inveterate  dyspepsia,  and  is  apt  to  come  on  in  severe  paroxysms, 
which  are  alarming  to  the  patient,  but  which  generally  disai)pear 
under  brisk  purging.  In  hypochondriacs  whose  abdominal  walls 
are  thin,  the  beating  at  the  epigastrium  may  become  a  source  of 
continued  study  and  distress. 

The  increased  action  of  the  aorta,  or,  as  ha23pens  in  emaciated 
persons,  the  greater  distinctness  with  which  the  beat  of  the  artery 
is  perceived,  without  there  being  really  much,  if  any,  abnormal 
throbbing,  may  be  distinguished  from  an  enlarged  and  somewhat 
displaced  heart  by  the  circumstances  of  the  case  and  the  absence 
of  any  physical  signs  of  cardiac  disease ;  and  from  an  aneurism, 
by  the  mode  of  invasion,  and  by  the  want  of  those  signs  which, 
as  will  be  presently  described,  characterize  an  aneurism. 

Abdominal  Aneurism. — Aneurism  of  the  abdominal  aorta 
is  a  disease  of  middle  life,  and  of  males.  Its  most  frequent  cause 
is  excessive  muscular  exercise ;  sometimes  it  is  produced  by  a  blow 
on  the  abdomen,  or  by  syphilis.  Its  duration  is  very  uncertain  : 
occasionally  six  or  seven  years  elapse  from  its  earliest  indications 
until  the  fatal  termination ;  not  unusually  the  patient  lives  twenty 
to  thirty  months  after  the  outbreak  of  the  complaint. 

The  chief  symptoms  are  pain,  and  an  absence  of  dropsy,  of 
fever,  or  of  any  considerable  constitutional  disturbance.  The  pain 
is  generally  felt  in  the  back,  or  in  the  right  hypochondrium,  or 
shooting  down  the  sciatic  nerves  to  the  lower  limbs.  It  may  be 
constant  and  dull,  or  occur  in  protracted  and  violent  paroxysms ; 
ordinarily  there  is  a  persistent  pain  which  has  periods  of  fierce 
exacerbation.      The  disproportion  between  its  violence  and  the 


662  MEDICAL    DIAGNOSIS. 

otherwise  almost  unimpaired  liealth  is  a  sti-ikinii'  and  common 
feature  of"  the  disease,  and  is  apt  to  continue  until  the  aneurisni  be- 
comes very  large  and  occasions  displacement  of  important  organs. 

The  j^^tysical  )>-i(/ns  of  an  abdominal  aneurism  are  :  an  impulse 
communicated  to  the  hand  when  placed  over  the  swelling;  a  sys- 
tolic blowing  sound  ;  a  thrill ;  and  in  some  instances  a  distinct 
prominence  and  alteration  in  the  form  of  the  abdomen.  The  im- 
pulse corresponds,  Avith  rare  exceptions,  to  the  beat  of  the  heait, 
is  single,  and  ordinarily  very  forcible.  Generally  it  cannot  be  felt 
from  behind;  it' is  a  beat  discerned  only  anteriorly  and  on  either 
side  of  the  pulsating  sac.  Corresponding  to  the  throbbing  of  the 
tumor,  we  often  hear  a  short  bloAving  sound,  to  be  detected  both 
posteriorly  and  anteriorly,  s<»metimes  perceived  in  the  recumbent 
posture  only ;  or  a  dull,  mufBed  sound ;  rarely  are  there  two  sounds. 
A  thrill  felt  at  the  same  time  as  the  pulsation  is  not  unfrequently 
noticed  ;  still,  it  may  be  absent,  even  in  large-sized  aneurisms. 

Aneurism  of  the  abdominal  aorta  may  be  confounded  with — 

Rheumatism;  Neuealgia;  Colic; 

Disease  of  the  Spine; 

AoETic  Pulsation  ; 

Lumbar  and  Psoas  Abscess  ; 

non-aneurismal  pulsating  tumor. 

The  first  four  of  these  aifections  are  likely  to  be  mistaken 
for  an  abdominal  aneurism,  on  account  merely  of  the  pain  ;  the 
others,  because  of  the  presence  of  pulsation,  or  of  a  swelling,  or 
of  both  pulsation  and  swelling. 

Rheumatism;  Neuralgia;  Colic. — The  pain  caused  by  an  aneu- 
rism may  closely  simulate  rheumatism  of  the  lumbar  muscles,  or 
sciatica,  or  abdominal  neuralgia,  or  colic.  There  is  nothing  in 
the  pain  itself  which  will  lead  to  the  detection  of  its  origin  :  this 
can  be  effected  only  by  a  recognition  of  the  physical  signs  of  the 
aneurism.  When  these  are  not  well  defined,  the  diagnosis  is 
doubtful.  Yet,  even  when  they  are  slightly  marked  or  absent, 
if  the  pain  be  very  obstinate,  and  we  have  excluded  the  affections 
named  or  cannot  trace  them  to  their  usual  causes,  we  shall  often 
be  right  in  attributing  the  pain  to  an  aneurism.  This  is  espe- 
cially true  as  regards  abdominal  neuralgia  occurring  in  males, — 
a  disorder  which  ought  always  to  make  us  examine  for  an  aneu- 
rism, and  which  is  not  unfrequently  found  to  be  due  to  it. 


ABDOMINAL    PUL.SATIOX.  G63 

Disease  of  the  Spine. — Patients  who  arc  sufi'ering  from  aneurism 
often  complain  of  pain  in  the  spine,  and  present  sometimes  an 
obvious  spinal  curvature.  But  a  careful  examination,  by  detect- 
ing the  physical  signs  of  an  aneurism,  will  generally  enal)le  us  to 
distinguish  the  source  of  the  trouble.  The  constant  boring  pain 
so  much  complained  of  in  cases  of  aneurism  is  usually  thought  to 
be  due  to  absorption  of  the  vertebrae ;  but,  as  Stokes  proved,  it 
has  no  necessary  connection  with  this  lesion. 

Aortic  Pulsation. — Simple  abdominal  pulsation,  such  as  we 
observe  in  hysteria,  in  dyspepsia,  and  in  pregnancy,  or  excessive 
epigastric  pulsation  due  to  an  enlarged  right  ventricle  or  to  insuf- 
ficient aortic  valves,  may  be  readily  mistaken  for  an  aneurism. 
But  in  the  former  case  the  history  will  generally  lead  us  to  a  cor- 
rect conclusion,  especially  if  taken  in  connection  with  the  facts 
that  the  pulsation  is  not  heavy  and  slow,  as  in  an  aneurism,  but 
jerking  and  sudden ;  that  there  is  no  thrill ;  no  tumor  with  cor- 
responding dulness  on  percussion,  if  we  except  pregnancy ;  no 
systolic  murmur  audible  in  front  of  the  abdomen  or  along  the 
spine  ;  and  no  pain. 

The  pulsation  due  to  disease  of  the  heart  is  discriminated  by  the 
physical  signs  in  the  thorax.  Regurgitation  at  the  aortic  orifice, 
which  is  the  cardiac  affection  most  liable  to  be  confounded  with 
an  aneurism,  on  account  of  the  marked  pulsation  it  may  occasion 
in  the  left  hypochondrium  or  at  the  scrobiculus  cordis,  is  distin- 
guished by  the  single  or  double  blowing  sounds,  which  are  heard 
not  only  over  the  thorax,  but  also  over  so  many  arteries  of  the 
body,  and  by  the  character  of  the  pulse. 

Lumbar  and  Psoas  Abscess. — In  some  cases,  soft,  fluctuating, 
deep-seated  tumors,  Avhich  are  really  produced  by  an  aneurism, 
may  arise  in  the  lumbar  region ;  nay,  they  may  seem  to  point,  as 
happens  in  psoas  abscess,  at  Poupart's  ligament.  But,  unlike  an 
abscess,  the  effusions  of  blood  give  rise,  with  rare  exceptions,  to 
impulse  and  to  murmur. 

Non-aneurismal  Pulsating  Tumors. — When  a  tumor  of  any 
kind  presses  upon  the  aorta,  a  distinct  pulsation  is  communicated, 
and  the  similarity  to  an  aneurism  is  heightened  by  the  circum- 
stance that  the  morbid  growth  may  produce  a  murmur.  The 
tumors  which  most  usually  occasion  the  phenomena  mentioned 
are :   enlargement  of  the  left  lobe  of  the  liver,  cancer  of  the 


664  MEDICAL   DIAGNOSIS. 

pylorus,  disease  of  the  pancreas,  or  of  the  onientuni,  or  of  the  mes- 
entery, and,  in  rarer  instances,  enlargement  and  distention  of  the 
kidney,  fiecal  aci-umulations,  and  cancer  of  the  lumbar  glands. 

Kow,  to  avoid  error,  we  must  pay  close  attention  to  the  history 
of  the  disorder ;  we  must  trace,  by  percussion,  the  outline  of  the 
solid  mass,  and  see  if  it  correspond  with  any  viscus ;  we  must  lay 
stress  on  the  presence  of  digestive  disorders,  and  on  the  amount 
of  constitutional  disturbance, — both  of  which  are  so  slight  in  ab- 
dominal aneurism  ;  we  must  examine  the  urine  carefully,  and  find 
out  whether  there  are  renal  symptoms  in  the  case.  Then,  in  non- 
aneurismal  tumor  the  patient  has  almost  always  been  in  bad  health 
before  the  tumor  is  detected,  and  the  swelling  rarely  causes  pain  of 
such  severity  as  is  observed  in  an  aneurism  ;  moreover,  the  trans- 
mitted aortic  impulse  is,  as  a  rule,  lessened  by  placing  the  patient 
on  his  hands  and  knees,  thus  taking  away  the  pressure  from  the 
artery.  A  varicose  state  of  the  epigastric  veins  and  the  existence 
of  ascites  will  also  decide  against  an  aneurism  ;  while,  on  the  other 
hand,  the  lateral  as  well  as  the  forward  direction  of  the  impulse, 
violent  neuralgic  pains  in  the  loins  or  shooting  down  the  back,  and 
an  immovable  tumor,  are  in  its  favor.  Still,  there  are  cases  in 
which  a  morbid  growth  lying  across  the  aorta  occasions  symptoms 
so  nearly  like  those  of  an  aneurism  that  the  most  skilful  diagnos- 
tician finds  himself  in  doubt. 

There  are  cases  of  aneurism  in  which  the  physical  signs  are 
absent,  and  in  which  the  affection  affords  no  indication  of  its 
existence,  beyond,  perhaps,  pain.  Under  these  circumstances  we 
can  only  suspect  its  occurrence. 

But  supposing  that,  from  the  combination  of  the  physical  signs 
and  svmptoms,  we  know  that  we  are  dealing  with  an  abdominal 
aneurism,  can  we  be  sure  that  it  is  aortic  ?  We  cannot ;  for, 
although  this  is  generally  its  seat,  an  aneurism  of  the  splenic 
or  the  cteliac  artery,  of  the  superior  mesenteric  artery,  or  of  the 
renal  artery,  may  produce  the  same  phenomena.* 

When  an  aneurism  bursts,  it  gives  rise  to  symptoms  which  vary 
with  the  seat  of  the  rent.  The  accident  is  always  fatal,  but  death 
may  not  follow  for  several  days ;  usually  great  tenderness  of  the 
abdomen  and  changes  in  the  physical  signs  are  at  once  produced. 

*  See  Ballard,  Physical  Diagnosis  of  Diseases  of  the  Abdomen,  p.  217. 


CHAPTER   VII. 

ON   THE   UKINE,   AND   ON   DISEASES   OF   THE   UKINARY 

ORGANS. 

Before  discussing  the  diseases  of  the  urinary  organs  with 
which  the  practitioner  of  medicine  has  to  deal, — mainly  those  of 
the  kidney, — I  shall  briefly  notice  the  urine  in  its  pathological 
and  clinical  aspects. 

UEINE. 

The  main  function  of  the  kidneys  is  to  remove  water  and  nitro- 
gen from  the  system,  at  the  same  time  that  they  take  from  the 
blood  many  of  its  salts.  The  excreted  liquid  contains  a  variety 
of  substances,  and  by  its  study  we  are  enabled  to  arrive  not  only 
at  the  condition  of  the  organ  which  prepares  it,  but  also  at  the 
state  of  the  circulating  fluid,  and  often  indirectly  at  that  of  several 
viscera,  the  disorders  of  which  give  rise  to  impurities  in  the  blood, 
which  the  kidneys  endeavor  to  eliminate.  Hence  the  urine,  besides 
being  the  most  accurate  index  of  the  condition  of  the  urinary 
organs,  becomes  a  fair  indication  of  that  of  many  other  important 
secreting  glands  in  the  body;  and,  further,  throws  light  on  the 
workings  of  the  nervous  system. 

To  glean  the  full  benefit  from  an  analysis  of  the  urine,  we  must 
explore  it  not  merely  qualitatively,  but  quantitatively,  and  examine 
its  deposits  with  the  microscope.  Modern  chemistry  is  especially 
endeavoring  to  find  means  which  will  bring  it  within  the  power  of 
every  one  to  determine,  by  apt  volumetric  processes,  the  exact  pro- 
portion of  the  ingredients  as  accurately  and  as  easily  as  hitherto  we 
have  detected  their  presence.  This  is  a  subject  which  cannot  be 
more  than  indicated  in  these  pages :  only  such  of  these  ingenious 
investigations  will  be  noticed  as  have  furnished  results  which 
may  be  made  readily  available  for  the  exigencies  of  professional 
life. 

665 


6GG  MEDICAL   DIAGNOSIS. 

It  is  customary,  in  quantitative  analyses,  to  use  the  French 
system  of  measures,  and  to  employ  instruments  on  which  cubic 
centimetj'es  are  marked.  One  thousand  cubic  centimetres  are 
equal  to  one  litre,  or  2.1  U.S.  pints,  or  to  a  thousand  grammes 
of  water;  and  one  gramme  is  equal  to  15.434  grains;  one  centi- 
gramme to  .1543  of  a  grain. 

Urine,  in  its  normal  state,  is  of  acid  reaction,  amber-yellow 
color,  and  of  specific  gravity  of  1018  to  1025  as  com])ared  Avitli 
distilled  water  at  1000.  On  standing  from  eight  to  twelve  hours, 
a  slight  cloudy  deposit  takes  place,  consisting  mainly  of  mucus, 
epithelial  cells  from  the  urinary  passages,  and  a  few  crystals. 

The  manner  of  obtaining  a  specimen  of  urine  is  not  unimpor- 
tant. We  should  instruct  our  patient,  as  is  so  strongly  recom- 
mended by  Sir  Henry  Thompson,*  to  pass  the  first  two  ounces 
into  one  vessel,  and  the  remainder  into  another.  We  thus  procure 
a  specimen  of  the  renal  secretion,  in  addition  to  anything  in  the 
bladder,  separate  from  any  urethral  products,  and  avoid  the  error 
of  confounding  prostatic  or  urethral  with  vesical  or  renal  disease. 
When  it  is  essential  to  obtain  a  specimen  of  urine  absolutely  pure 
and  unmixed  with  products  of  the  bladder,  the  same  authority 
recommends  the  drawing  oif  of  the  urine  bv  means  of  a  soft  gum 
catheter,  while  the  patient  is  standing.  The  bladder  should  then 
be  carefully  washed  out  by  repeated  one-ounce  injections  of  warm 
M^ater.  The  urine  is  now  to  be  permitted  to  pass,  as  it  will  do, 
drop  by  drop,  into  a  small  glass  vessel.  The  bladder  contracts 
around  the  catheter,  and  the  urine  percolates  direct  from  the  ure- 
ters, through  their  virtual  prolongation, — the  catheter, — into  the 
receptacle.  The  urine  passed  in  the  morning,  immediately  after 
rising,  will  be  found  to  represent  with  sufficient  accuracy  the 
general  process  of  disassimilation  ;  but,  if  greater  accuracy  be  de- 
sirable, a  specimen  of  the  mixed  urine  of  the  twenty-four  hours 
should  be  used. 

As  regards  the  quantity  of  urine  daily  voided,  Hofmann  and 
Ultzmann,  and  other  recent  observers,  determine  the  mean  average 
of  healthy  persons  to  be  1500  cubic  centimetres  (fifty  fluidounces). 
In  summer,  when  the  skin  is  acting  freely,  less  fluid  passes  off  by 
the  kidneys  than  in  winter.     The  more  liquid  that  is  taken  into 

*  Clinical  Lectures  on  Diseases  of  the  Urinarv  Orcrans. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS. 


GG7 


the  system,  the  greater  is  the  secretion  of  urine,  unless  the  other 
organs  which  eliminate  water,  as  the  skin,  lungs,  and  intestines, 
are  excreting  with  unwonted  activity. 

The  quantity  is  diminished  in  all  cases  in  which  the  s])ecific 
gravity  is  increased,  with  the  exception  of  diabetes ;  it  is  dimin- 
ished in  acute  diseases,  in  fevers,  in  cholera,  and  in  the  early  stages 
of  dropsies  ;  in  some  forms  of  Bright's  disease  through  their  en- 
tire course,  and  for  the  most  part  in  the  last  stage  of  all  forms 
of  that  disease.  It  is,  on  the  other  hand,  augmented  in  all  cases 
in  which  the  specific  gravity  is  diminished  :  in  hysteria ;  in  the 
atrophic,  nodular  kidney,  in  the  contracted  kidney,  and  in  waxy 
disease.  In  almost  all  vesical  and  kidney  aifeetions  frequent 
micturition  is  a  marked  symptom, — not  always,  however,  asso- 
ciated with  increased  quantity  of  urine. 

The  ingredients  of  urine  are  numerous.  The  principal  are : 
urea,  sulphates,  phosphates,  chlorides,  uric  acid  and  urates,  kreat- 
inin,  hippuric  acid,  mucus,  coloring-matter,  and  a  large  proportion 
of  water. 

The  following  table,  by  Parkes,  shows  the  composition  of  nor- 
mal urine,  the  figures  representing  the  amount  passed  in  twenty- 
four  hours  by  a  male  adult  weighing  sixty -six  kilogrammes  (one 
hundred  and  fifty  pounds). 

Water 1500.00  grammes. 

Urea 33.18 

TJric  acid .55  " 

Hippuric  acid .40  " 

Kreatinin .91  " 

Pigment  and  other  substances  10.00  " 

Sulphuric  acid 2.00  " 

Phosphoric  acid 3.16  " 

Chlorine 7.00  " 

Ammonia 0.77  " 

Potassium 2.50  " 

Sodium 11.90  " 

Calcium 26  " 

:             Magnesium .27  " 

Besides  the  elements  mentioned,  the  quantities  of  which  fluctu- 
ate with  the  food-supply  and  with  the  activity  of  tissue-metamor- 
phosis, and  vary  especially  when  the  system  is  deranged,  we  meet, 
in  morbid  states,  with  substances  that  do  not  exist  at  all  in  healthy 


668  MEDICAL   DIAGNOSIS. 

urine,  or  the  presence  of  which  is  doubtliil,  siuJi  as  various  forms 
of  albumen,  sugar,  blood,  bile,  fats,  oxalate  of  lime,  and  certain 
pigments.  jNlost  of  these  are  dissolved  in  the  urine,  and  are  not 
to  be  detected  except  by  chemical  tests ;  others  form  in  sediments 
after  the  urine  has  been  discharoed,  and  mav  be  at  once  recoo;nized 
by  the  microscope. 

Having  thus,  in  a  general  manner,  mentioned  the  constituents 
of  the  urine,  normal  and  accidental,  let  us,  in  the  same  general 
manner,  look  at  the  points  of  clinical  interest  to  be  decided  by  an 
analysis ;  in  t)ther  words,  let  us  ascertain  what  the  physician,  not 
the  professed  chemist,  is  in  quest  of.  And  here  it  may  be  stated 
that  we  are  always  somewhat  guided  by  our  knowledge  of  the 
case.  We  should,  for  instance,  be  most  likely  to  look  for  albu- 
men in  dropsical  affections ;  or  for  sugar  where  a  large  quantity 
of  urine  was  habitually  passed. 

Usually,  we  endeavor  to  fix  all  of  these  waymarks  :  the  specific 
gravity,  the  color,  the  quantity,  the  reaction,  the  presence  or  absence 
of  such  important  abnormal  ingredients  as  albumen  and  sugar,  and 
the  character  of  the  deposits.  Frequently,  too,  we  extend  our  ex- 
amination until  we  have  determined  approximately,  if  not  accu- 
rately, the  increase  or  diminution  of  the  main  constituents  of  the 
urine,  especially  of  the  urea,  uric  acids,  chlorides,  phosphates,  and 
sulphates,  and  the  distribution  or  non-distribution  of  bile  and  other 
unusual  constituents  through  the  fluid.  Let  us  examine  these  points 
more  in  detail. 

Color. — The  color  of  the  urine  is  much  affected  by  food  and 
medicine,  as  well  as  by  various  morbid  processes ;  so  rapidly,  in- 
deed, affected,  that  we  nmst  be  chary  of  drawing  conclusions  from 
the  appearance  of  the  secretion  alone.  Yet  we  suspect  the  pres- 
ence of  certain  substances,  or  are  nearly  positive  of  their  absence, 
by  the  appearance  of  the  fluid.  Thus,  a  smoky  or  a  red  aspect  is 
apt  to  be  owing  to  admixture  of  blood  ;  a  very  light  color  denotes 
generally  an  increase  of  water,  and*  is  commonly  found  in  dia- 
betes, in  hysteria,  and  in  kindred  nervous  affections.  In  febrile 
diseases  the  urine  is  of  dark  hue.  A  greenish-yellow  or  brown- 
ish tint  of  the  discharge  is  indicative  of  bile  ;  but  a  similar  tinge 
may  be  present  when  rhubarb  has  been  taken.  A  dirty-blue  urine 
happens  from  an  indigo  sediment;  it  is  alkaline,  and  occurs  chiefly 
in  typhus  and  in  cholera.     Strong  coffee  darkens  the  urine  ;  tur- 


THE    URINE,  AND    DISEASES    OF   THE    URINARY    ORGANS.       669 

pentine  darkens  and  imparts  a  violet  odor  to  it ;  carl)oli<i  acid,  tar, 
and  creasote  render  it  black  ;  so  do  disintegrated  blood  and  mel- 
anotic cancer.  Santonin,  logwood,  and  senna  discolor  it.  The 
first-named  substance  gives  it  a  bright  yellow  color,  which  on  the 
addition  of  an  alkali  becomes  crimson.*  Senna  may  impart  to  it 
a  brownish  or  a  deep  red  color,  which,  however,  like  that  due 
to  rhubarb,  is  lightened  on  the  addition  of  mineral  acids,  and  is 
thus  distinguished  from  the  hue  of  urine  containing  blood.  The 
altered  appearance  is  mostly  due  to  the  coloring-matter  of  these 
articles  being;  excreted  with  the  urine. 

The  chemistry  of  the  coloring-matters  of  the  urine  is  still  incom- 
plete, and  the  clinical  significance  of  the  color-changes  still  obscure. 
The  principal  normal  coloring-matter  is  urobilin,  which  is  an  oxida- 
tion-product from  blood  and  bile-pigment.  In  febrile  conditions 
a  less  oxidized  product  is  excreted,  which  MacMunn  has  named 
pathological  urobilin  and  declares  to  be  identical  with  the  color- 
ing-matter of  the  fgeces,  stercobilin.  He  further  states  that  the 
presence  of  this  body  in  the  urine  is  to  a  certain  extent  an  indi- 
cation of  the  absorption  of  faecal  matter  and  ptomaines  which 
have  not  been  destroyed  by  the  liver.  Other  pigments  have  been 
described,  among  which  may  be  named  urohsematojporphyrin  and 
uroerythrin.  The  employment  of  the  spectroscope  is  one  of  the 
means  of  distinguishing  between  these  colors,  but  a  description 
of  their  minute  differences  would  be  beyond  the  scope  of  this 
work. 

Specific  Gravity. — We  take  the  specific  gravity  of  urine  to 
judge  of  the  solid  matter  it  contains.  The  readiest  means  is  the 
urinometer.  For  the  implement  to  yield  trustworthy  results  the 
fluid  should  be  brought  to  the  temperature  at  which  the  uri- 
nometer has  been  graduated, — generally  60°  F.  A  difference  of 
7°  F.  corresponds  with  about  1  degree  of  the  urinometer.  More 
accurate  than  the  urinometer  is  the  specific  gravity  bottle,  or  the 
Westphal  balance. 

If  there  be  but  a  small  quantity  of  urine  for  examination,  we 
note  the  amount  and  how  many  volumes  of  distilled  water  it  takes 
to  fill  the  vessel  to  the  height  required  to  float  the  urinometer. 
We  then  multiply  the  number  above  1000  that  the  instrument 


*  Smith,  Dublin  Quarterly  Journal,  Nov.  1870. 


670  MEDICAL   DIAG^'OSIS. 

shows,  bv  the  total  number  of  vohimcs  of  the  mixed  fluid.     This 
is  only  approximate. 

From  the  specific  gravity  we  may  calculate  approximately  the 
(piantity  of  solid  matter  passed  by  multiiilyinii;  the  number  above 
lOOU  by  2  for  the  specific  gravities  below  1018,  and  by  2.33  for 
those  above.  This  may  be  done  \vhether  we  estimate  in  grammes 
or  in  grains.  For  instance,  in  urine  of  specific  gravity  of  1010 
there  will  be  20  grains  of  solid  matter  in  each  1000  grains  of 
urine;  in  urine  of  1030,  69.90  grains.  This  information  ob- 
tained, it  is  easy  to  find  the  whole  amount  of  solids  contained  in 
the  urine  of  twenty-four  hours  after  ascertaining  first  the  quan- 
tity passed  in  that  time.  To  take  the  first  illustration  :  if  1000 
grains  yield  20  of  solid  matter,  how  much  would  be  yielded  by 
20,000  (the  quantity  passed,  we  will  say,  in  twenty-four  hours)  ? 
1000  :  20  :  :  20,000  :  x.     a;  =  400  grains. 

This  method  is  not,  however,  very  precise ;  indeed,  where  ex- 
actness is  required,  the  urine  must  be  evaporated  until  a  dry 
residue  is  left,  which  should  then  be  carefully  weighed. 

The  amount  of  solids  in  healthy  urine  is  variously  estimated. 
Beale  places  it  approximately  at  from  800  to  1000  grains  in 
twenty-four  hours ;  Hofmann  and  Ultzmann  at  60  to  70  grammes, 
— about  920  to  1080  grains, — and  in  persons  who  are  fasting,  or 
have  taken  little  food,  as  in  fevers,  at  30  grammes  in  the  twenty- 
four  hours.  As  a  "general  rule,  the  proportion  is  greatest  in  per- 
sons of  heavy  weight :  if,  therefore,  we  wish  to  make  nice  com- 
parisons, the  weight  of  the  body  should  always  be  stated.  To 
ascertain  how  much  of  the  solid  matter  consists  of  the  salts,  the 
organic  substances  must  be  driven  off  at  a  red  heat. 

In  disease,  the  solids,  and  with  them  of  course  the  specific  grav- 
ity, fluctuate  very  much.  We  find  the  specific  gravity  decidedly 
increased,  rising  to  1030  or  higlier,  when  sugar  or  an  excess  of 
urea  is  present,  and  when  the  urine  is  concentrated  and  of  deep 
color.  A  low  specific  gravity  is  met  with  in  certain  forms  of 
Bright's  disease,  in  many  cases  of  hysteria,  and  in  all  pale  urines 
except  that  of  diabetes.  But  to  be  accurate — and,  indeed,  accu- 
racy in  regard  to  the  other  physical  and  chemical  properties  is 
unattainable  without  attending  to  the  same  rule — we  must  not 
lay  stress  on  the  specific  gravity  without  taking  into  account  the 
measure  of  urine  passed  in  the  twenty-four  hours,  as  well  as  the 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       G71 

quantity  of  drink  and  of  food  swallowed ;  all  of  which  of  ne- 
cessity influences  the  specific  gravity.  So,  too,  does  the  activity 
of  the  tissue-metamorphosis. 

Reaction. — Normal  urine  reddens  blue  litmus-paper.  The 
acidity  depends  upon  acid  salts,  especially  acid  sodium  phosphate. 
The  degree  of  acidity  is,  even  in  health,  not  always  equal,  and 
is  much  influenced  by  digestion.  If  no  food  have  been  taken  for 
hours,  the  discharge  is  highly  acid ;  that  passed  after  a  meal,  and 
while  the  process  of  digestion  is  going  on,  is  but  faintly  so,  or 
neutral,  or  even  alkaline.  In  about  three ,  or  four  hours  after 
meals  the  alkaline  tide  turns,  and  the  acidity  of  the  urine  slowly 
increases  until  food  is  again  taken.  There  seems,  however,  to  be 
a  limit  to  the  increase  of  acidity,  for  Bence  Jones  found  that  con- 
tinuing to  fast  for  twelve  hours  beyond  the  usual  meal-time  did 
not  intensify  the  acidity  of  the  urine.  The  alkalinity  of  the  urine 
after  meals  is  rarely  detected  at  the  bedside.  For,  although  the 
urine  may  be  alkaline  when  secreted  by  the  kidneys,  it  is  generally 
mixed  in  the  bladder  with  that  which  collected  before  or  after  the 
alkaline  tide,  and  the  mixed  urine  when  passed  may  have  an  acid 
reaction.  Roberts  attributes  the  occurrence  of  the  alkaline  tide 
after  meals  to  the  entrance  of  the  newly-digested  food  into  the 
blood. 

The  acidity  of  the  urine  is  augmented  by  the  administration  of 
the  vegetable  or  the  mineral  acids ;  yet  they  do  not  cause,  even 
in  large  doses,  as  great  variations  as  does  digestion.  We  find  the 
urine  very  acid  during  a  meat  diet.  We  find  acidity  of  the  urine 
strongly  marked  if  any  acid  be  present  in  it  which  sets  the  uric 
acid  free,  or  if  this  be  in  decided  excess. 

For  determining  reaction,  litmus-paper  is  used.  Solution  of 
litmus  is  divided  into  two  parts  ;  to  one  part  nitric  acid  is  added, 
drop  by  drop,  until  the  color  is  wine-red.  This  is  then  mixed 
with  the  other  half.  Slips  of  filtering-paper  are  dipped  in  this 
and  dried.  They  have  a  purple  tint,  and  are  very  delicate,  re- 
sponding to  a  trace  either  of  free  acid  or  of  alkali.  We  thus 
avoid  the  use  of  two  colors.  Litmus-paper  is  best  kept  in  a 
closed  dark  bottle. 

We  estimate  the  amount  of  free  acid  in  the  urine  by  a  solution 
of  sodium  hydroxide  (caustic  soda),  or  by  a  solution  of  sodium 
carbonate,  containing  53  grammes  to  the  litre,  or  530  grains  to 


672  MEDICAL    DIAGNOSIS. 

10,000  grains.  Some  of  this  solution  is  addod  drop  by  dro])  to 
100  ee.  of  urine,  wliic-h  has  boon  measured  off  in  a  beaker  glass. 
After  the  addition  of  each  half  cubic  centimetre,  a  drop  of  the 
mixture  is  placed,  bv  means  of  a  glass  rod,  on  \vell-j)repared 
litmus-paper.  "When  the  paper  is  no  longer  reddened,  the  analy- 
sis is  finished  ;  and  by  noting  how  much  of  the  standard  solution 
has  been  used,  we  can  determine  the  aeidity  of  the  urine,  which 
it  is  customary  to  express  as  equal  to  so  many  grains  of  oxalic 
acid,  that  being  the  substance  used  to  determine  the  activity  of 
the  soda  solution,  each  cc.  of  which  must  indicate  10  milligrammes 
of  oxalic  acid. 

Urine,  when  voided,  remains  ordinarilv  acid  for  at  least  a  day ; 
but  it  may  lose  its  acidity  much  sooner.  This  is  always  a  signifi- 
cant fact,  having  much  the  same  meaning  as  if  the  fluid  had  been 
discharged  in  a  neutral  or  an  alkaline  state. 

Now,  an  alkaline  reaction  may  result  from  several  causes  :  from 
the  effect  of  digestion,  as  already  mentioned  ;  from  the  ])resence  of 
a  fixed  alkali,  as  sodium  or  potassium  carbonate ;  or  from  the  de- 
composition of  the  urea  into  ammonium  carbonate.  In  the  for- 
mer case,  heat  does  not  restore  the  color  of  the  red  litmus-paper — 
it  remains  blue ;  in  the  latter,  a  gentle  heat  soon  brings  back  the 
original  red  tint.  Moreover,  in  either  case,  the  earthy  phosphates 
are  precipitated,  the  fixed  carbonate  causing  the  precipitation  of 
the  amorphous  calcium  phosphate ;  while  by  the  ammonium  car- 
bonate ammonium  and  magnesium  phosphates,  in  conjunction 
with  the  calcium  phosphate,  are  thrown  down,  and  the  triple 
phosphate  is  abundantly  formed,  and  can  be  easily  recognized 
under  the  microscope  by  its  prismatic  crystals. 

Alkalinity  of  the  urine  from  fixed  alkali  is  not  inconsistent 
with  health.  We  have  adverted  to  the  effects  of  digestion ;  and 
alkaline  urine  also  results  from  the  use  of  certain  articles  of  vege- 
table food,  or  of  the  salts  of  sodium  and  potassium  administered 
as  medicine.  Urine  owing  its  alkalinity  to  ammonium  carbon- 
ate is  always  to  be  viewed  as  pathological.  The  disturbance  is 
generally  long  continued,  and  the  urine  loses  its  acidity  in  the 
bladder,  in  consequence  of  a  disease  of  the  mucous  coat  of  the 
viscus,  or  from  being  long  retained  there,  as  in  cases  of  paraplegia, 
or  from  admixture  with  pus,  which  acts  as  a  kind  of  ferment 
and  leads  to  decomposition  of  the  urea. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY   ORGANS.       673 

Changes  in  the  Quantity  of  the  more  Important  Con- 
stituents of  Urine. —  Urea. — The  amount  of  urea  excreted  }jy 
well-nourished,  healthy,  adult  males  in  the  twenty-four  hours  is 
estimated,  in  round  numbers,  by  Roberts  at  3|  grains  per  pound 
weight  of  the  body,  and  by  Neubauer  and  Vogel  at  25  to  40 
grammes,  or  0.37  to  0.60  gramme  for  every  kilogramme  of  weight 
of  the  body.  Thus  the  amount  is  very  variable  ;  but  it  is  not  so 
variable  that  a  study  of  the  quantity  may  not  be  useful  for  ])rac- 
tical  purposes.  Urea  is  the  principal  product  of  the  change  of 
nitrogenized  substances.  Its  proportion  fluctuates,  therefore,  with 
the  food  partaken  of,  as  well  as  with  the  activity  of  the  trans- 
formation of  the  structures  of  the  system :  hence  it  becomes  the 
most  important  index  of  the  waste  and  repair  of  tissues.  Ex- 
ertion of  body  and  of  mind  leads  to  the  discharge  of  a  larger 
quantity  of  urea.  If  this  be  replaced  by  a  nourishing  diet,  noth- 
ing is  lost ;  the  body  retains  its  health.  But  when  the  requi- 
site amount  of  nitrogenized  aliment  is  not  taken,  or,  if  taken, 
cannot  be  assimilated,  owing  to  a  disturbance  in  digestion,  the 
person  wastes.  We  notice,  too,  in  acute  febrile  states,  until  their 
height  is  reached,  hand  in  hand  with  the  emaciation,  an  increase 
of  this  significant  urinary  constituent, — a  proof,  then,  of  the  rapid 
and  unsupplied  disintegration  of  the  tissues.  We  see  the  same 
increase  during  paroxysms  of  intermittent  fever,  in  inflamma- 
tions, and  in  some  cases  of  nervousness ;  also  from  a  predomi- 
nant animal  diet,  and  in  certain  forms  of  indigestion,  in  which 
the  food  is  speedily  passed  off  in  the  shape  of  urea  instead  of 
acting  its  part  in  the  nutrition  of  the  economy.  Degenerative 
changes  in  the  liver  may  be  accompanied  by  a  diminution  of 
urea-excretion. 

A  lessened  quantity  of  urea  is  excreted  during  fasting,  from 
an  almost  exclusive  vegetable  diet,  in  dropsies,  and  in  many  long- 
continued  organic  diseases  which  gradually  undermine  the  general 
nutrition  and  diminish  tissue-change,  or  in  states  attended  with 
diminished  oxidation.  But  the  diminished  amount  in  the  urine 
may  also  be  due  to  a  want  of  secreting  power  of  the  kidneys. 
The  urea,  or  the  products  of  its  decomposition,  then  act  as  a  poison 
in  the  blood  ;  and  the  symptoms  classed  as  uraemic  poisoning  are 
encountered.  Urea  is  sometimes  not  found  in  the  urine  at  all,  or 
only  in  traces,  having  been  replaced  by  leucine  and  tyrosine. 

43 


674 


MEDICAL    DIAGNOSIS. 


Quantitative  estimations  of  uiva  are  now  almost  always  made 
bv  the  use  of  either  sodium  hypoehlorite  or  sodium  hypobromite, 
whieh  causes  the  liberation  of  the  nitrogen,  the  volume  of  which 
is  approximately  proportional  to  that  of  the  urea  present.  The 
sodium  hypochlorite  solution  may  be  obtained  ready  for  use,  under 
the  name  of  Labarraque's  solution.  The  hypobromite  solution 
must  be  prepared  as  needed.  The  results  obtained  by  the  latter 
are  more  accurate,  but  it  is  doubtful  if,  for  ordinary  clinical  pur- 
poses, the  diiference  in  fesult  compensates  for  the  much  greater 
inconvenience  and  even  danger  attending  the  use  of  bromine. 
Lyons  states  that  a  solution  having  substantially  the  eifect  of  the 
hypobromite  may  be  obtained  by  adding  about  one  gramme  of 
potassium  bromide  to  25  cc.  of  Labarraque's  solution,  w^hich  should 
be  of  good  quality.  Many  forms  of  apparatus  have  been  sug- 
gested.     The  simple  one  designed  by  Doremus,  shown  in  the 

cut,  will  be  found  to  answer  all 
^i<5.  44.  purposes.    If  it  be  desired  to  use 

the  hypobromite  solution,  it  may 
be  prepared  by  dissolving  170 
grains  of  caustic  soda  in  water  and 
adding  80  minims  of  bromine. 
This  liquid  may  be  preserved  for 
a  short  time  in  a  well-stopi^ed 
bottle,  but  does  not  keep  well. 
The  mixing  must  be  conducted 
in  a  well- ventilated  place,  as 
bromine  is  exceedingly  irritating 
and  corrosive. 

For  use,  the  apparatus  figured 
is  filled  with  the  solution  so  that 
when  upright  the  liquid  partly 
fills  the  large  bulb.  A  large 
watch-glass  or  a  shallow  dish  may 
be  placed  under  the  tube,  to  catch  any  overflow.  A  measured 
quantity  of  the  urine  is  then  introduced  by  means  of  the  dropping- 
tube,  the  opening  of  this  being  pushed  well  into  the  bend  of  the 
upright  tube ;  the  apparatus  is  tilted  a  little  forward,  to  insure  that 
no  gas-bubbles  or  urine  escape  into  the  large  bulb.  After  about 
twenty  minutes  the  volume  of  nitrogen  gas  is  read  off.     1  cc.  of 


THE    URINE,  AND    DISEASES    OP   THE    URINARY    ORGANS.       G75 


Fig.  45. 


nitrogen  may  be  taken  to  correspond  to  .0028  of  a  gramme 
(.04  of  a  grain)  of  urea.  Another  simple  and  efficient  apjiaratus 
has  been  suggested  by  Greene.* 

A  method  for  fixing  the  quantity  of  urea  approximately  is  that 
proposed  by  Haughton.  It  consists  in  the  use  of  tables  showing 
how  many  grains  of  urea  are  excreted  in  the 
urine,  of  which  the  amount  daily  passed 
and  the  specific  gravity  are  predetermined. 
On  the  following  page  is  the  table,  as 
abridged  by  Roberts.  It  can,  for  practical 
purposes,  be  depended  on,  except  when 
sugar  or  albumen  is  present. 

A  rough  way  of  estimating  the  urea  is 
to  drop  nitric  acid  into  a  porcelain  capsule 
holding  urine  which  has  been  evaporated 
to  a  mucilaginous  consistence.  Crystals  of 
pearly  lustre,  in  which  the  microscope 
shows  the  characteristic  shape  of  nitrate 
of  urea,t  are  develojDed. 

Uric  Acid. — Uric  acid,  like  urea,  is  a 
product  of  the  metamorphosis  of  tissue. 
It  was  supposed  by  Liebig  that  the  acid  is  an  early  stage  of  the 
transformation  of  urea.  Hofmann  teaches  that  uric  acid  is  de- 
posited owing  to  the  decomposition  of  the  urates  by  the  acid  phos- 
phate of  sodium.  Under  ordinary  circumstances,  the  deposition 
of  uric  acid  occurs  subsequently  to  the  expulsion  of  the  urine ;  but 
should  the  acid  sodium  phosphate  be  in  excess,  the  uric  acid 
may  be  precipitated  before  the  secretion  is  voided,  and  thus  give 
rise  to  gravel  and  calculi.  This  may  also  happen  through  too 
great  concentration  of  the  urine. 

The  amount  of  uric  acid  passed  in  twenty-four  hours  is  0.5  of  a 
gramme.  It  corresponds  in  general  to  the  amount  of  urea  in  the 
proportion  of  1  to  45.  In  normal  urine  the  presence  of  uric  acid 
cannot  be  detected  without  the  addition  of  a  strong  acid,  since  it 
exists  in  the  form  of  soluble  urates,  which  must  be  first  decom- 
posed.    The  uric  acid  is  gradually  thrown  down  in  small  red 


Greene's  ureomcter. 


*  Medical  Times,  Phila.,  Jan.  12,  1884. 

f  This   shape   changes    to   pencillated   needles   when   albuminuria   exists. 
Hofmann,  "Zoochemie." 


676 


l^IEDICAL   DIAGNOSIS. 


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THE   URINE,  AND    DISEASES   OF   THE   URINARY   ORGANS.      677 

grains,  which,  should  it  be  desirable  to  determine  the  quantity  of 
the  acid,  are  washed,  dried,  and  carefully  weighed.  The  quantity 
of  uric  acid  may  be  approximately  estimated  by  mixing  100  cc.  of 
the  urine  with  5  cc.  of  strong  hydrochloric  acid  and  allowing  it 
to  stand  in  a  cool  place  for  two  days.  The  separated  crystals 
are  then  collected,  washed  with  a  little  water,  and  weighed.  A 
correction  of  .0038  of  a  gramme  for  100  cc.  of  liquid  used  in 
washing  should  be  added  to  allow  for  solubility. 

The  characteristic  reaction  of  uric  acid  is  furnished  by  the 
murexide  test.  A  few  drops  of  nitric  acid  are  mixed  with  the 
suspected  deposit  in  a  capsule,  and  the  mixture  is  slowly  evap- 

FiG.  46. 


Crystols  of  uric  acid,  magnified  about  200  diameters.    Moet  of 
these  forms  are  seen  in  tlie  urine  of  acute  rheumatism. 

orated  nearly  to  dryness  over  a  lamp ;  a  drop  of  ammonia  is 
then  added,  which  produces  instantly  a  rich  purple. 

But  both  uric  acid  and  the  urates  can  be  easily  and  quickly 
discriminated  by  the  microscope.  The  crj^stals  of  uric  acid  are 
readily  discerned,  notwithstanding  that  they  vary  both  in  size  and 
in  form.  Rhombic  plates  with  rounded  angles  are  frequent.  To 
obtain  the  crystals  rapidly,  where  they  are  not  passed  as  uric  acid, 
a  portion  of  the  suspected  deposit  is  dissolved  in  a  drop  of  potassa, 
and  the  alkaline  solution  then  treated  with  an  excess  of  acetic 
acid  :  after  the  lapse  of  a  few  hours  crystals  of  uric  acid  will  be 
formed. 

In  disease,  the  fluctuations  in  the  quantity  of  uric  acid  are 


678  MEDICAL   DIAGNOSIS. 

great ;  as  a  o-cuoral  rule,  they  correspond  to  tlie  rise  and  fall  of 
urea.  We  find  the  aeid  diminished  in  hydruria  and  ailections  in 
which  the  eliminating  power  of  tlie  kidneys  is  interfered  with,  as 
in  the  more  advanced  stages  of  Bright's  disease  and  in  anjoniia  and 
chlorosis.  An  increase  is  encountered  in  acute  iiiHammations,  in 
fevers,  in  functional  disorders  and  many  of  the  structural  affections 
of  the  liver,  in  heart  and  lung  diseases  attended  with  dyspnoea,  in 
leukaemia,  and  in  acute  rheumatism.  In  the  latter  malady  the 
little  red  granules,  visible  to  the  naked  eye,  form  a  deposit  in  the 
urine  soon  after  it  is  voided. 

We  must,  however,  be  careful  not  to  suppose  the  uric  acid  to 
be  in  excess  because  it  is  readily  precipitated.  It  may  or  may 
not  be  in  larger  amount :  the  sediment  merely  proves  an  aug- 
mentation of  acidity  in  the  urine  sufficient  to  take  away  the  base 
from  the  uric  acid.  This  happens  often  as  the  result  of  acid  fer- 
mentation of  the  urine.  Frequently  urates  are  separated  along 
with  the  uric  acid ;  we  find  then  generally  a  dark  urine  of  high 
specific  gravity  and  of  very  acid  reaction. 

Persons  who  habitually  pass  urine  of  the  character  described 
are  subject  to  gastric  or  hepatic  disorders.  They  are  also  often 
gouty,  or  of  lithsemic  tendencies,  and  frequently  consumers  of  a 
large  amount  of  animal  food,  or  intemperate  or  indolent  in  their 
habits.  Hence  it  is  not  uncommonly  perceived  that  exercise  in 
the  open  air,  regulating  the  diet,  attention  to  the  action  of  the 
skin,  and  the  use  of  mild  aperients,  by  tending  to  eliminate  the 
acid  and  by  keeping  the  blood  from  becoming  vitiated,  afford  more 
real  and  permanent  benefit  than  the  exhibition  simply  of  alkalies 
to  neutralize  the  acidity  of  the  urine. 

Uric  acid  or  urates  are  never  found  as  sediments  in  freshly- 
voided  healthy  urine.  Occasionally  precipitates  of  uric  acid  or 
urates  occur  in  the  vunnary  passages.  Now,  these  sediments  may 
concrete  and  form  the  nuclei  of  calculi ;  or  .they  may  be  passed  in 
small  particles,  cornmonly  spoken  of  as  "gravel." 

Urates. — The  pathological  conditions  in  which  the  urates  are 
changed  are  much  the  same  as  those  in  which  alterations  in  uric 
acid  occur.  They  are  principally  the  sodium,  potassium,  and  am- 
monium urates.  The  deposits  formed  by  their  precipitation  are 
of  pink  color,  sometimes  brown,  or  like  brick -dust,  or  yellowish, 
or  even  white.     From  pale  urine  of  low  specific  gravity  a  white 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       679 

sediment  is  apt  to  settle.  All  the  deposits  are  dissolved  with 
readiness  by  heat.  Acids  decompose  them  and  separate  uric  acid. 
They  are  all  more  soluble  in  warm  water  than  in  cold,  and  the 
neutral  salts  are  more  soluble  than  the  acid  ones. 

Under  the  microscope,  the  urates  are  seen  to  be  either  irregular, 
amorphous  particles,  needle-like  crystals,  dumb-bells,  or  round 
globules  of  various  sizes,  from  some  of  which  fine  needles  project. 
The  latter,  like  the  dumb-bells,  are  commonly  supposed  to  be 
sodium  urate ;  the  globules  and  crystals,  sodium  urate  and  am- 
monium urate ;  the  granular,  amorphous  powder,  mixed  urates, 
more  especially  sodium  urate  and  potassium  urate.  These  amor- 
phous urates  may,  under  the  microscope,  be  mistaken  for  calcium 

Fig.  47. 


Mixed  urates. 


phosphate.  The  differential  test  consists  in  their  behavior  with 
acids :  the  phosphate  is  dissolved  by  acetic  or  hydrochloric  acid ; 
the  urates  are  gradually  transformed  into  crystals  of  uric  acid. 
Then,  a  deposit  of  calcium  phosphate  is  often  more  cloudy  than 
the  urates,  and,  unlike  them  or  uric  acid,  is  not  soluble  in  liquor 
potassse.  From  calcium  carbonate,  which  also  occurs  in  a  granu- 
lar form,  both  the  urates  and  the  calcium  phosphate  are  distin- 
guished by  the  effervescence  of  the  carbonic  acid  which  happens 
on  the  addition  of  a  strong  acid. 

Urine  containing  a  sediment  of  urates  is  generally  markedly 
acid,  or  soon  becomes  so,  either  from  an  absolute  increase  of  the 
uric  acid,  or  in  consequence  of  changes  in  some  of  the  constituents 


680  MEDICAL   DIAGNOSIS. 

of  the  fluid — as  of  the  pigment — which  take  place  either  before  or 
shortly  after  emission.  Not  unfrequently,  too,  it  is  scanty,  and 
the  urates  are  deposited  as  soon  as  the  urine  cools  to  the  tempera- 
tiu'e  of  the  atmosphere.  Their  precipitation  may  be,  and  indeed 
often  is,  due  to  there  not  being  water  enough  to  hold  them  in 
solution.  We  may  judge  of  this  being  the  case  by  ascertaining 
the  amount  of  urine  passed  in  twenty-four  hours.  If  the  quantity 
be  about  normal,  the  deposit  is  in  all  likelihood  due  to  an  excess 
of  urates.  In  cold  weather  these  deposits  occur  more  quickly  and 
more  extensively  tluin  in  w^arm. 

Sediments  of  urates  are  at  times  met  with  in  pale  urine,  and 
without  either  diminution  of  water  or  excess  of  acidity.  The 
urine  yields  but  a  faintly -acid  or  a  neutral  or  an  alkaline  reaction, 
and  under  the  latter  circumstances  calcium  phosphate,  or  even 
triple  phosphates,  may  be  observed  to  accompany  the  urates.  The 
urate  present  is  acid  ammonium  urate. 

Pliosphates. — The  phosphates  are  derived  in  part  from  the  food, 
in  part  from  the  disintegration,  or  rather  the  oxidation,  of  the 
disintegrated  albuminous  substances,  and  especially  of  the  nerve- 
structures.  They  occur  either  as  calcium  and  magnesium  plios- 
phates, the  earthy  •phosphates,  which  exist  in  small  amounts,  about 
1  gramme  in  twenty-four  hours,  and  as  sodium  phosphate,  about 
three  times  as  abundant,  forming  the  greater  part  of  the  alkaline 
phosphates. 

In  health  the  phosphates  are  kept  in  solution  by  their  acidity  ; 
but  as  soon  as  the  urine  ceases  to  be  acid  they  are  deposited. 
Hence  the  appearance  of  phosphates  bespeaks  a  neutral  or  an 
alkaline  condition  of  the  urine,  with  the  exception  that  calcium 
phosphate  may  occur  in  acid  urine.  Often  the  fluid,  as  Ave  have 
already  seen,  becomes  alkaline  from  the  decomposition  of  the 
urea  into  ammonium  carbonate.  This  acts  upon  the  ])hosphate, 
forming  ammonio-magnesium  phosphates,  which  crystallize  com- 
monly in  transparent  prisms  or  in  feathery-looking  bodies,  easily 
distinguished  from  the  amor2:)hous  powder  or  small  round  globules 
of  calcium  phosphate.  Yet  there  is,  as  Roberts  has  pointed  out, 
a  crystalline  form  of  calcium  phosphate  which  might  be  mistaken 
for  one  of  the  stellar  forms  of  uric  acid,  but  it  may  be  distinguished 
by  its  being  invariably  colorless.  These  earthy  phosphates  are  all 
readily  soluble  in  acids,  even  in  Aveak  acids  like  acetic  acid,  and 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    GROANS.       681 

this  at  once  distinguishes  them,  even  under  the  microscope,  from 
calcium  oxalate,  which  some  forms  resemble.  In  many  speci- 
mens of  urine  they  are  precipitated  by  heat ;  but  the  addition  of 
an  acid  soon  dissolves  them,  and  thus  prevents  the  turbidity  from 
being  mistaken  for  that  due  to  albumen. 

The  triple  phosphates  are  often  met  with  in  heavy  deposits 
mixed  with  pus,  especially  in  the  alkaline  purulent  urine  resulting 
from  chronic  vesical  catarrh.  They  are  also  seen  in  cases  of  re- 
tention of  urine  due  to  temporary  or  permanent  paralysis  of  the 
bladder,  as  in  low  fevers,  in  hemiplegia,  or  in  paraplegia.  They 
are  found,  too,  in  many  affections  in  which  the  vital  powers  have 

Fig.  48. 


Earthy  phosphates  ;  the  granules  are  chiefly  calcium  phosphate, 
the  rest  triple  phosphates. 

been  seriously  lowered  and  the  acidity  of  the  urine  diminished, 
as  during  convalescence  from  acute  disease.  Under  the  latter 
circumstances,  and  in  fact  whenever  the  urine  has  become  alkaline 
from  the  presence  of  a  fixed  alkali,  the  phosphatic  deposit  is  apt 
to  show  a  large  excess  of  the  amorphous  phosphates,  if,  indeed,  it 
do  not  altogether  consist  of  them. 

Urine  alkaline  from  fixed  alkali,  and  depositing  phosphates,  is, 
unless  this  condition  have  been  brought  about  temporarily  by 
fruit  or  other  food,  a  matter  of  serious  import.  We  encounter  it 
in  persons  laboring  under  great  general  debility  and  indigestion 
associated  with  an  impaired  tone  of  the  nervous  system, — in  fact, 
in  those  of  whom  it  has  been  the  custom  to  speak  as  exhibiting  the 


682  MEDICAL   DIAGNOSIS. 

".pliospluitic  diathesis."  Such  a  morbid  state  is  not  uncommon 
in,  men  depressed  by  mental  toil  or  anxiety. 

In  these  cases,  in  spite  of  the  distinct  sediment  of  the  phos- 
phates, it  is  very  doubtful  if  the  latter  are  really  increased  in 
quantity.  The  want  of  the  acidity  of  the  urine  permits  their  pre- 
cipitation, and  causes  them  to  become  readily  apparent ;  just  as  it 
is  with  reference  to  deposits  of  urates,  where  the  sediment  may  be 
entirely  due  to  the  altered  reaction  of  the  urine,  and  not  to  exces- 
sive elimination.  On  the  other  hand,  the  phosphates  may  be  ac- 
tually in  excess,  and  yet  this  excess  be  concealed  from  view.  This 
happens  especially  with  the  alkaline  phosphates,  the  proportions  of 
which  change  in  disease  much  more  than  do  the  earthy  phosphates, 
and  indicate  much  more  clearly  the  variations  of  the  phosphoric 
acid.  And,  paradoxical  as  it  may  appear,  the  acidity  of  the  urine 
may  be  so  much  augmented  by  the  increase  of  the  phosphoric  acid 
that  a  very  large  excess  of  alkaline  phosphates  may  be  present  in 
solution  in  a  highly-acid  urine. 

Now,  a  real,  not  merely  an  apparent,  increase  of  the  phosphates 
occurs,  according  to  Bence  Jones,  in  acute  inflammatory  diseases 
of  the  nervous  structure,  and  in  fractures  of  the  skull  when  an  in- 
flammatory action  takes  place  in  the  brain.  It  also  occurs  after 
mental  strain.  Beale,  however,  does  not  regard  the  excess  of 
phosphates  as  being  a  sign  of  wear  and  tear  of  nervous  tissue. 
We  find  the  phosphates  also  augmented  by  the  abundant  use  of 
animal  food,  by  very  active  exercise,  and  in  acute  rheumatism. 
The  earthy  phosphates  are  markedly  increased  in  rickets  and 
in  extensive  bone  disease ;  the  phosphoric  acid,  as  well  as  the 
sulphuric  acid,  the  urea,  and  the  sodium  chloride,  is  excreted 
in  less  amount  than  in  health  during  the  course  of  a  maniacal 
paroxysm,  in  epilepsy,  and  in  melancholia.* 

To  determine  the  pro])ortion  of  the  earthy  phosphates,  a  few 
drops  of  ammonia  are  added  to  the  urine ;  soon  a  whitish  precipi- 
tate is  produced,  which  is  not  removed  by  heat.  From  the  quan- 
tity of  the  deposit,  after  settling,  we  may  form  a  rough  estimate 
of  that  of  the  earthy  phosphates.  In  an  ordinary-sized  test-tube  a 
deposit  1  c.  high  represents  a  normal  amount.  But  if  the  amount 
is  to  be  accurately  ascertained,  we  must  employ  a  graduated  glass, 

*  Adam  Addison,  Brit,  and  For.  Med.-Chir.  Kev.,  April,  1865. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       683 

separate  the  precipitated  phosphates  by  filtration,  ignite  them  in  a 
platinum  capsule,  and  weigh  the  ash.  The  alkaline  phosphates 
are  not  thrown  down  by  alkalies,  and,  unlike  the  earthy  phosphates, 
are  very  soluble  in  water.  They  are  procured  by  taking  the  fluid 
from  which  the  earthy  phosphates  have  been  carefully  removed 
by  filtration,  and  adding  to  it  a  saturated  solution  of  magnesium 
sulphate.  Or  we  add  to  the  urine  about  one-third  as  much  of 
the  magnesium  mixture,  and  if  the  precipitate  be  copious,  giving 
the  fluid  the  appearance  of  cream,  then  the  alkaline  phosphates 
are  in  excess;  if  there  be  merely  a  milky  turbidity,  they  are 
normal. 

From  the  deposit  obtained  in  testing  for  the  phosphates,  some 
idea  may  also  be  formed  of  the  quantity  oi  phosphorie  acid  in  the 
urine.  The  average  quantity  passed  by  an  adult  male  in  twenty- 
four  hours  is,  according  to  Vogel,  about  3.5  grammes,  or  nearly 
53  grains.  For  the  volumetric  processes  by  which  the  amount 
of  the  acid  may  be  determined,  I  refer  to  special  treatises  on  the 
chemistry  of  the  urine, — to  such  works  as  those  of  Neubauer, 
Beale,  and  Thudichum. 

Chlorides. — The  chlorides  in  the  urine  are  derived  from  the 
food  ;  they  correspond  closely  with  the  amount  of  salt  ingested. 
In  consequence,  the  sodium  chloride — the  main  chloride  in  the 
urine,  for  it  contains  but  little  potassium  chloride  and  calcium 
chloride  —  is,  even  in  health,  liable  to  great  fluctuations;  the 
mean  in  twenty-four  hours  is  estimated  by  Vogel  and  Parkes  at 
11.5  grammes,  or  about  177  grains.  Bischofi'  states  the  average 
at  14.73  grammes.  Large  quantities  of  chlorides  are  excreted  after 
active  bodily  or  mental  exercise,  smaller  quantities  when  the  body  is 
at  rest,  as  at  night.  In  disease,  very  various  amounts  are  elimi- 
nated with  the  urine.  In  cases  of  chronic  indigestion,  of  dropsy, 
and  during  an  ague-fit,  the  chlorides  are  diminished.  In  typhus 
fever  and  in  acute  inflammatory  affections  they  sink  to  a  low  level, 
and  rise  again  in  convalescence  :  an  increase  after  a  diminution  is 
thus  always  a  favorable  sign.  We  may  study  these  changes  in 
pleurisy  and  pericarditis,  but  especially  in  pneumonia.  At  the 
period  of  hepatization  the  chlorides  are  absent  from  the  urine,  and 
appear  in  increased  quantity  in  the  sputum  ;  during  resolution  they 
reappear  in  the  urine ;  between  these  stages  there  is,  probably,  a 
determination  of  the  salt  to  the  inflamed  orran. 


G84  MEDICAL   DIAGNOSIS. 

Sodium  chloride  is  detected  bv  acidulating  the  urine  with  nitric 
acid  and  adding  a  solution  of  silver  nitrate ;  a  dense  white  pre- 
cipitate of  silver  chloride  quickly  appears,  insoluble  in  nitric  acid, 
but  soluble  in  ammonia.  The  amount  of  the  chloride  is  approx- 
imately estimated  by  comparison  ^\■ith  healthy  urine,  or  by  em- 
ploying the  method  of  Hofmann  and  Ultzmann.  According  to 
this  method,  if  in  using  a  solution  of  silver  nitrate  of  definite 
strength,  1  to  8,  we  find  curdy  masses  of  silver  chloride  lalling 
to  the  bottom,  which  on  shaking  the  glass  do  not  separate,  we 
judge  the  chlorides  to  be  in  normal  amount.  If  the  prccij)itat'e 
of  silver  chloride  be  small,  j^^  per  cent,  or  less,  a  simple  milky 
turbidity  arises  and  no  curdy  mass  deposits ;  whereas  if  the 
chlorides  be  entirelv  wantino;  there  is  neither  milkv  cloud  nor 
turbidity.  If  the  urine  contain  much  albumen,  it  should  be  co- 
agulated and  filtered  off  before  the  test  is  applied. 

Sulphates. — Sulphates  are  found  in  the  urine  in  large  quantities. 
They  consist  of  potassium  sulphate  and  sodium  sulphate,  the  for- 
mer in  excess.  Like  the  alkaline  phosphates,  they  are  soluble  in 
the  urine.  To  detect  them,  a  few  drops  of  nitric  acid  are  added 
to  urine,  and  subsequently  from  fifteen  to  twenty  drops  of  a 
saturated  solution  of  barium  chloride,  when  a  white  precipitate 
insoluble  in  acids  occurs.  If  there  be  merely  an  opaque  milky 
cloudiness,  the  sulphates  are  in  normal  quantity. 

The  sulphates  are  obtained  in  part  from  the  food,  in  part  from 
the  oxidation  of  the  sulphur  entering  into  the  constitution  of  the 
albuminous  substances  of  the  body  and  the  subsequent  union  with 
a  base  of  the  sulphuric  acid  which  is  formed.  They  are  enhanced 
by  an  exclusively  animal  diet,  and  after  violent  exercise,  and  in 
acute  febrile  processes  with  large  excretion  of  urea ;  in  fact,  their 
increase  is  apt  to  go  hand  in  hand  with  that  of  urea.  An  excep- 
tion to  this  is  noticed  by  Parkes*  in  rheumatic  fever.  Here  the 
sulphuric  acid  in  the  urine  is  greatly  augmented,  but  the  urea  not 
correspondingly  so.  The  administration  of  potassium  raises  in  a 
striking  degree  the  proportion  of  the  sulphates.  The  sulphates 
show  decrease  during  an  exclusively  vegetable  diet  and  in  urine 
of  low  specific  gravity. 

The  average  daily  quantity  of  sulphuric  acid  passed  in  the  urine 


*  British  and  Foreign  Medico-Chirurgical  Review,  vol.  xiii. 


THE    URINE,  AND    DISEASES    OF   THE    URINARY    ORGANS.       G85 

is  about  2  grammes.  Vogcl  gives  an  easy  method  of  determining 
approximately  whether  it  is  increased  or  diminished.  After  ascer- 
taining the  whole  amount  of  urine  in  twenty-four  hours, — say  it 
is  2000  cc,  and  then  each  100  cc.  would  contain  0.10  gramme  of 
sulphuric  acid, — 100  cc.  are  rendered  acid,  and  as  much  of  a  test- 
solution  of  barium  chloride*  is  added  as  corresponds  with  0.05 
gramme  of  the  acid.  The  mixture  is  now  filtered,  and  if  the 
filtered  liquid  be  not  made  turbid  by  the  barium  chloride,  we 
may  infer  that  the  patient  has  secreted  less  than  1  gramme  of 
sulphuric  acid  in  the  twenty-four  hours.  If  the  liquid,  however, 
be  rendered  turbid  by  barium  chloride,  a  further  quantity  of  this 
agent,  corresponding  with  0.5  gramme  of  sulphuric  acid,  is  added ; 
and  if  the  filtrate  be  still  rendered  turbid,  it  is  evident  that  the 
quantity  of  sulphuric  acid  is  greater  than  normal.  In  addition 
to  the  sulphates  proper,  the  urine  contains  small  quantities  of 
derivatives  of  sulphuric  acid,  known  as  the  sulphonates,  one  of 
which  is  phenol-sulphonic  acid.  The  origin  of  these  bodies  is 
believed  to  be  in  some  way  connected  with  the  action  of  putre- 
factive processes  dependent  on  micro-organisms,  but  as  yet  no 
definite  information  as  to  their  exact  clinical  significance  is  at 
hand.' 

Kreatin  and  Kreatinin. — These  substances  found  in  the  urine 
are  purely  excrementitious,  and  are  derived  from  a  disintegration 
of  the  muscular  tissue.  Kreatinin  is  the  product  of  the  change 
of  kreatin.     About  1  gramme  is  excreted  daily. 

But  few  observations  have  as  yet  been  made  on  the  increase  of 
kreatin,  or  on  its  significance  in  showing  the  activity  of  nutrition 
in  the  muscles  in  health  or  in  disease.  Active  muscular  exercise 
augments  the  quantity ;  and  the  same  effect  is  probably  produced 
by  all  spasmodic  affections,  and,  as  Munk  has  shown,  at  the  height 
of  acute  disease,  while  kreatin  is  diminished  during  convalescence, 
and  in  advanced  degeneration  of  the  kidneys. 

Both  kreatin  and  kreatinin  are  generally  included,  in  analyses, 
under  the  head  of  nitrogenous  bodies.  Under  the  microscope 
the  crystals  of  kreatin  are  colorless  and  beautifully  transparent. 


*  Made  generally  by  dissolving  30.5  grammes  of  crystallized  barium  chlo- 
ride, powdered  and  air-dried,  and  diluting  the  solution  up  to  1  litre ;  1  cc.  of  it 
then  equals  10  milligrammes  of  sulphuric  anhydride. 


686  MEDICAL    DIAGNOSIS. 

Their  appoaranoo,  as  well  as  that  of  krcatinin,  is  failhfully  rcpre- 
se-nted  in  Kohin  and  Yenleirs  plates.* 

Presence  of  Abnormal  Substances  in  the  Urine. — Here 
may  be  mentioned  tiie  ingredients,  sneh  as  bile  and  blood,  ob- 
served in  the  urine  in  disease  only;  and  along  with  them  I  shall 
notice  those  constituents  the  occurrence  of  which  in  healthy  urine 
is  occasional,  but  of  which  it  is  certain  that  their  presence  in  any 
marked  degree  is  abnormal. 

Oxalate  of  Lime,  Calcium  Oxalate. — There  can  be  no  doubt 
that  this  may  occasionally  be  detected  in  the  urine  of  persons 
who  enjoy  good  health ;  but  equally  there  can  be  no  doubt  that 
the  crystals  are  not  found  in  large  numbers  except  in  a  morbid 
condition.  Some  pass  habitually  a  considerable  quantity  of  it. 
They  are  generally  persons  weighed  down  by  care  and  anxiety,  or 
who  overtask  their  brains  by  incessant  application  to  study,  or 
weaken  their  nervous  power  by  excessive  sexual  indulgence  or  by 
masturbation.  Sometimes  they  are  troubled  Avith  frequent  semi- 
nal emissions  and  irritation  of  the  bladder,  or  they  are  dyspeptic, 
and  suffer  from  uneasiness  after  meals ;  but  the  appetite  may  be 
good  and  the  digestion  unimpaired.  They  are  always  languid, 
and  either  very  irritable  or  very  dejected.  Frequently  they  com- 
plain of  loss  of  memory,  and  of  a  sensation  of  weight  or  of  a  dull 
pain  across  the  loins.  They  are  liable  to  boils  and  carbuncles, 
grow  thin,  and  evidently  are  generally  out  of  health.  The  urine  is 
of  high  specific  gravity,  shows  an  increase  of  urea,  and  ordinarily  a 
cloudy  deposit  consisting  of  mucus  and  the  crystallized  oxalates. 
Not  unfrequenlly  minute  traces  of  albumen  are  associated  with 
small  amounts  of  calcium  oxalate  in  urine  apparently  otherwise 
normal. 

This  is  the  disorder  called  by  Golding  Bird  oxaluria,  and 
is  arenerallv  combined  with  tissue-chano;es  and  increased  excretion 
of  urea.  Its  existence  as  a  separate  affection  has  been  denied ; 
but  that  the  formation  of  calcium  oxalate  in  any  considerable 
quantity  is  associated  with  the  symptoms  described,  can  be  satis- 
factorily ascertained  by  any  one  who  will  take  the  trouble  to  ex- 
amine the  urine  Avith  care,  in  cases  like  those  referred  to.  The 
origin  of  the  oxalic  acid,  however,  is  not  certain.     Golding  Bird 

*  Traite  de  Chimie  anatomique,  Paris,  1853. 


THE   URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       687 

attributed  it  to  a  secondary  or  destructive  assimilation  of  tissue. 
The  evidence  is  certainly  in  favor  of  its  being  formed  in  the  system, 
for  it  has  been  found  in  the  blood.  Still,  it  is  not  improbable  that 
it  may  at  times  be  the  product  of  a  species  of  fermentation  oc- 
curring in  the  urinary  passages,  and  therefore  after  the  urine  is 
secreted  ;  and  it  is  known  that  oxidation  of  uric  acid  and  the  urates, 
and  the  imperfect  oxidation  of  sugar,  of  starch,  and  of  the  salts  of 
the  vegetable  acids,  may  occasion  it.  Probably  in  the  first  class  of 
cases  alone  are  the  constitutional  symptoms  described  present.  In 
the  others  we  may  at  times  detect  evidence  of  the  irritation  of  a 
calculus,  or  of  disease  of  the  bladder  or  the  kidneys. 

Fig.  49. 


Calcium  oxalate  crystals.' 

Calcium  oxalate  may  be  detected  in  the  urine  when  articles 
which  contain  it,  such  as  sorrel  and  the  rhubarb  plant,  have  been 
eaten,  or  after  the  free  use  of  carbonated  drinks.  It  may  be  also 
found  in  the  urine  of  those  recovering  from  severe  acute  maladies, 
and  is  encountered,  but  only  in  very  small  quantities,  in  the  urine 
of  healthy  persons.  But  in  neither  instance  is  it  at  all  permanent, 
nor  can  the  presence  of  a  few  crystals  be  looked  upon  as  of  the 
least  importance. 

The  microscope  is  incomparably  the  readiest  means  of  detecting 
the  salt.  This  appears  in  the  urine  in  well-defined  octahedra  of 
most  varying  size,  and  in  dumb-bell  bodies.  The  former  are 
much  the  more  common  and  characteristic,  for  the  dumb-bells  are 


688  MEDICAL    DIAGNOSIS. 

not  frequent,  nor  is  this  formation  peculiar  to  calcium  oxalate. 
Occasionally,  long  or  pointed  octahedra  or  prismatic  crystals  are 
observed.     All  forms  arc  unaffected  by  acetic  acid. 

The  oxalates  are  often  mixed  Avith  deposits  of  urates  or  uric 
acid  ;  a  fact  Avhich  some  use  as  an  argument  that  oxalic  a(!id  is  but 
the  direct  transformation  of  uric  acid,  just  as  othei's  regard  it  as  a 
louer  degree  of  oxidation  than  is  necessary  to  form  the  jiroducts  of 
disintegration  into  urea.  Sometimes — Bcneke  says  constantly — 
the  earthy  phosphates  coexist  in  large  amount  with  the  oxalates. 
Occasionally  the  irritation  from  the  passage  of  the  crystals  gives 
rise  to  tube-casts.  A  case  came  under  my  observation  years  since 
in  which  a  patient  suffering  from  a  protracted  attack  of  oxaluria 
voided  for  weeks,  along  with  the  oxalates,  hyaline,  exudative,  or 
small  waxy  casts.  Neither  heat  nor  nitric  acid  detected  albumen. 
Under  treatment,  the  crystals  disappeared  from  the  urine,  and  with 
them  the  casts.  The.  gentleman  recovered  perfectly.  The  urine 
examined  ten  years  afterwards  showed  not  the  slightest  signs  of 
degeneration  of  the  kidneys. 

Leucine  and  Tyrosine. — Both  these  substances  are  the  result  of 
the  decomposition  of  highly  nitrogenous  animal  matter,  are  very 
similar,  and  are  usually  associated.  They  replace  urea,  and  have 
been  found  in  the  urine  only  in  disease,  as  in  yellow  atrophy  of  the 
liver,  in  typhoid  fever,  in  smallpox,  in  phosphorus-poisoning,  in 
cancer  of  the  liver.*  They  are  either  spontaneously  deposited,  or 
form  a  deposit  if  a  small  quantity  of  urine  be  evaporated.  Tyro- 
sine is  readily  detected  by  the  microscope.  It  crystallizes  in  long, 
very  fine,  shining  needles,  which  may  congregate  in  globular  bodies. 

Hofraann  has  proposed  the  following  delicate  chemical  test  for 
tyrosine.  A  solution  of  mercuric  nitrate,  nearly  neutral,  is  to  be 
treated  with  the  solution  suspected  to  contain  tyrosine :  if  it  be 
present,  a  reddish  precipitate  is  produced,  and  the  supernatant 
fluid  is  of  a  very  dark  rose-color.  Leucine  crystallizes  in  gran- 
ular masses,  consisting  of  roundish  globules,  sometimes  of  con- 
centric form,  and  for  the  most  part  of  yellowish  color,  and 
resembling  oil-drops,  but,  unlike  oil,  is  not  dissolved  by  ether. 
The  chemical  test  for  leucine  is  to  place  the  suspected  deposit 


*  Vaughan  and  Beringer,  Contributions  from  the  Chemical  Laboratory  of 
the  University  of  Michigan,  vol.  i.,  1882. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       089 

on  platinum  foil  and  then  to  evaporate  it  with  nitric  acid.  The 
residue  is  moistened  with  caustic  soda,  and  this  mixture  is  care- 
fully heated  over  a  spirit-lamp.  It  is  gradually  condensed  into 
oily-looking  drops, — a  property  which  Scherer  has  pointed  out 
as  characteristic  of  leucine. 

Bile. — The  occurrence  of  bile  in  the  urine  imparts  to  it  a  very 
dark  color.  Its  presence  is  a  proof  that  the  bile  jmsses  into  the 
blood,  and  that  the  kidneys  are  performing  a  function  forced  on 
them  by  the  deranged  action  of  the  liver,  or  by  an  impediment  in 
the  biliary  passages.  All  the  constituents  of  the  bile  may  appear 
in  the  urine,  or  only  the  pigment,  without  the  acids  or  their  salts. 
The  pigment  is  sometimes  found  transiently,  and  in  small  quan- 
tities, without  yellowness  of  the  skin  :  its  more  permanent  and 
marked  occurrence  is,  however,  always  attended  with  jaundice. 
It  may  be  discerned  both  before  the  discoloration  of  the  skin  is 
noticeable,  and  after  it  has  lost  its  yellow  hue.  The  biliary  acids 
are  not  of  necessity  present  in  the  urine  of  icterus. 

The  detection  of  the  coloring-matter  of  bile  is  effected  by  pour- 
ing a  small  quantity  of  urine  on  a  white  plate ;  a  drop  of  nitric 
acid,  or,  better  still,  of  the  yellow  fuming  nitric  acid  of  commerce, 
is  then  permitted  to  fall  on  the  thin  layer  of  fluid.  Soon  a  play  of 
color  takes  place,  beginning  with  green  and  blue,  passing  to  violet 
and  red,  and  often  finally  to  yellow  or  brown ;  the  green  is  the 
predominant  and  the  most  characteristic  of  the  colors.  Accord- 
ing to  Frerichs,*  this  reaction  may  fail  in  cases  where  the  other 
symptoms  of  jaundice  are  undoubted,  owing  to  the  bile-pigment 
having  already  passed  through  stages  of  transformation.  When 
this  is  the  case,  the  urine  is  at  one  time  of  a  brown  or  brownish- 
red  color,  and  becomes  red  on  the  addition  of  nitric  acid ;  at 
another  time  it  is  of  a  deep  red,  ■^^'hich  is  converted  by  nitric  acid 
into  a  dark  bluish-red.  Murchison  has  made  a  similar  observation  f 
in  rare  cases  where  jaundice  has  resulted  from  a  blood-poison,  and 
he  has  frequently  found  the  urine  to  present  these  characters  where 
there  has  been  no  jaundice,  yet  obvious  derangement  of  the  liver. 

Heller's  test  is  also  very  easily  performed.  In  a  small  beaker 
glass  containing  about  6  cc.  (1.62  fluidrachms)  of  pure  hydro- 


*  Diseases  of  the  Liver,  Sydenham  Soc.  Transl.,  vol.  i.  p.  100. 
■j-  Clinical  Lectures  on  Diseases  of  the  Liver. 
44 


690  MEDICAL   DIAGNOSIS. 

ohlorio  aeid  mix  enough  urine  to  clificolor  this,  then  allow  nitric 
rteid  to  ti'iekle  along  the  sides  and  form  a  layer  undi'meuth.  A 
beautiful  play  of  colors  takes  place  at  the  point  of  contact,  and, 
on  stirring  up  the  mixture  witii  a  glass  rod,  throughout  it. 

Basham*  speaks  of  the  following  test  for  bile-pigment  as  being 
very  delicate.  The  urine  is  shaken  up  with  a  small  quantity  of 
chloroform,  which  dissolves  out  the  bile  coloring-matter  and  re- 
tains it  in  solution.  If  this  solution  be  decanted  and  evaporated 
carefully,  the  pigment  which  is  left  gives,  on  the  addition  of  a 
drop  of  nitric  acid,  a  beautiful  ruby-red  color,  after  displaying 
the  characteristic  play  of  colors.  This  test  is  equally  available 
for  detecting  bile-pigment  in  other  fluids. 

Another  delicate  test  for  bile-color  is  this.  A  fluidrachm  of 
the  urine  is  shaken  Avith  an  equal  volume  of  chloroform,  the 
liquids  are  allowed  to  settle,  the  chloroform  is  evaporated,  and 
the  residue  tested  by  a  few  drops  of  tincture  of  iodine.  In 
the  presence  of  the  bile-color — bilirubin — a  fine  green  color  will 
develop.  It  is  stated  that  no  other  ingredient  of  the  urine, 
pathological  or  normal,  behaves  in  this  manner. 

Carter  tells  nsf  that  urine  containing  an  excess  of  indican  pre- 
sents the  same  succession  of  colors,  when  treated  with  nitric  acid, 
as  urine  holding  bile-pigment  in  solution.  To  avoid  this  fallacy 
in  a  doubtful  case,  the  urine  should  be  treated  with  sulphuric  acid, 
as  already  described.  If  the  mixture  become  black  and  opaque, 
depositing  a  deep-blue  or  purple  precipitate  on  being  diluted  with 
water,  the  play  of  colors  may  be  attributed  to  the  excess  of 
indican. 

If  the  urine  contain  only  altered  biliary  coloring-matters  (bili- 
fusin),  they  may,  according  to  Hofmann  and  Ultzmann,  be  rec- 
ognized as  follows.  A  piece  of  clean  white  linen  is  dipped  into 
the  urine  and  then  allowed  to  dry  ;  it  is  discolored  brown.  Fur- 
ther confirmation  is  found  in  a  very  dark  reaction  for  urophsein 
(by  adding  about  double  the  quantity  of  urine  to  strong  sulphuric 
acid),  the  urine  appearing  not  garnet-red,  but  only  black.  A 
similar  reaction  is  produced  only  by  the  presence  of  sugar  and 
of  blood-coloring  matter,  both  of  which  can  be  excluded  by  the 
appropriate  tests. 

*  Eenal  Diseases.  t  Edinb.  Med.  .Journ.,  Aug.  1859,  p.  125. 


THE    URINE,  AND   DISEASES   OF   THE   URINARY   ORGANS.      691 

The  biliary  acids  are  sought  for  })y  Fettenkojer^ s  ted.  It  con- 
sists in  tincturing  with  a  few  drops  of  a  solution  of  sugar  a  small 
portion  of  urine  contained  in  a  test-tube  or  in  a  china  dish,  placed 
in  cold  water.  To  this  mixture  an  excess  of  concentratc;d  sulplui- 
ric  acid  is  added,  drop  by  drop.  The  fluid  assumes  a  yellowish- 
red  color,  which,  if  bile  be  present,  passes  into  a  crimson  or  violet. 
The  test  is  not  applicable  to  albuminous  urine,  unless  the  albu- 
men be  first  coagulated  and  separated.  And  it  is  inconclusive ; 
for  urine  containing  an  excess  of  indican  may  display,  when  thus 
treated,  a  reaction  exactly  similar  to  that  caused  by  the  bile  acids. 
Moreover,  Neubauer  and  Yogel  state  that  oleic  acid  and  albu- 
men give  analogous  reactions.*  The  spectrum,  which  shows  lines 
by  F  and  near  to  E,  aifords,  according  to  Schunck,  the  most  cer- 
tain test  of  bile  acid  ;  indeed,  minute  distinctions  between  the 
different  coloring-matters,  too,  cannot  be  attained  except  through 
spectroscopy. 

Sugar. — This  substance  is  not  a  normal  ingredient  of  urine,  or 
exists  only  in  traces  too  minute  to  be  detected  by  the  ordinary 
tests.  When  met  with  in  healthy  urine  it  is  probably  due  to  the 
decomposition  of  the  indican.  Sugar  may  be  found  occasionally 
in  the  urine  of  those  who  live  exckisively  on  a  starchy  diet,  or 
who  take  large  quantities  of  sugar ;  but  the  proportion  even  then 
is  very  small.  The  urine  secreted  while  under  the  influence  of 
turpentine,  ether,  chloroform,  chloral,  or  amyl  nitrite,  is  found  to 
respond  to  the  copper  tests  for  sugar.  And  Bordierf  has  grouped 
together  many  observations  which  led  him  to  conclude  that  saccha- 
rine urine  may  be  considered  as  an  almost  normal  occurrence  in 
the  stage  of  recovery  from  acute  diseases.  Measles,  pneumonia, 
erysipelas,  all  inflammatory  fevers,  are  liable  to  its  production 
during  convalescence.  It  may  be  detected  in  certain  lesions  of  the 
brain  and  spinal  cord.  At  Guy's  Hospital  the  urine  of  a  large 
number  of  patients,  laboring  under  various  complaints,  was  found 
in  several  instances,  particularly  in  cases  of  phthisis,  to  give  a 
more  or  less  marked  reaction  of  sugar.  J  But  a  large  and  persistent 
amount  occurs  only  in  diabetes. 

*  On  the  general  value  of  the  test  consult  Murchison  on  the  Liver,  and 
Neuhauer  and  Vogel's  Analysis  of  the  Urine, 
f  Archives  Generales  de  Medecine,  1868. 
X  Researches  on  Diahetes,  by  T.  W.  Pavy. 


G92  MEDICAL    DIAGNOSIS. 

Urine  holding  sugar  in  solution  is  light-colored,  of  high  specific 
gravity,  and  of  peculiar  smell.  It  rarely  deposits  sediments,  and 
the  excess  of  water  in  it  is  enormous. 

To  detect  the  presence  of  sugar,  several  tests  have  been  proposed, 
nearly  all  of  which  are  easy  of  application,  and,  whichever  be  em- 
ployed, when  alKunu'u  is  pi'cscnt  in  any  amount,  this  should  be 
first  separated  by  boiling  and  filtering. 

Trommcr'a  Test. — A  few  drops  of  a  solution  of  copper  sulphate 
are  dropped  into  the  test-tube  holding  the  urine.  Solution  of 
caustic  soda  is  now  added  in  excess.  If  the  fluid  be  saccharine, 
the  faint  greenish  tint  is  changed  to  a  deep  blue,  the  precipitate 
which  is  formed  when  the  alkali  is  first  added  being  soon  redis- 
solved.  On  heating  the  blue  mixture  it  becomes  brownish,  then 
yello\v,  and  finally  a  reddish-brown  mass  of  copper  suboxide 
is  thown  down,  very  different  from  the  flocculeut  or  greenish 
sediment  noticed  when  no  sugar  exists.  A  very  small  quantity 
of  sugar  can  detected  by  this  process :  but,  good  as  the  test  is,  it 
has  its  drawbacks;  for  sugar  is  not  the  only  substance  which 
possesses  the  power  of  reducing  the  salts  of  copper.  Chloral, 
cellulose,  kreatinin,  and  to  some  extent  uric  acid  and  the  urates, 
share  with  it  this  property.  Furthermore,  Beale  has  shown  that 
the  presence  of  ammoniacal  salts  will  prevent  the  precipitation 
of  the  suboxide  in  urine  containing  but  little  sugar. 

For  the  quantitative  determination  of  sugar,  Fehling's  solution 
is  generally  employed.  This  is  best  made  by  the  following  for- 
mula, in  which,  in  accordance  with  the  recommendation  of  Allen, 
the  quantity  of  Rochelle  salt  is  rather  greater  than  ordinarily 
given.  34.64  grammes  of  pure  crystallized  copper  sulphate  are 
dissolved  in  pure  water,  and  the  solution  is  made  up  to  500  cc. 
70  grammes  of  caustic  soda  in  sticks  and  180  grammes  of  j^ure 
Rochelle  salt  are  dissolved  in  400  cc.  of  water,  and  the  solution  is 
also  made  up  to  500  cc.  The  two  solutions  are  best  kept  in  sepa- 
rate well-stopped  bottles.  For  use  equal  quantities  are  mixed  as 
required.  To  determine  the  proportion  of  sugar  in  a  sample,  five 
cc.  of  each  solution  are  mixed,  diluted  with  about  an  equal  volume 
of  water,  and  brought  to  the  boiling-point,  in  a  porcelain  basin. 
The  porcelain  dish  with  handle,  called  a  casserole,  is  very  conve- 
nient for  this  purpose.  No  precipitate  nor  loss  of  color  should 
result  from  the  boiling  of  the  solution.     The  sample  of  urine  is 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       693 

then  run  in  by  small  portions  at  a  time,  boiling  between  each  ad- 
dition, and  watching  the  liquid  so  as  to  note  the  point  at  which 
all  the  blue  color  is  removed.  The  condition  is  best  determined  by 
withdrawing  the  basin  from  the  flame  from  time  to  time,  inclining 
slightly,  and  allowing  the  red  precipitate  to  settle.  Any  trace 
of  blue  color  is  easily  seen.  Every  ten  cc.  of  the  Fehling's  solu- 
tion requires  .05  gramme  of  glucose  to  reduce  it  completely ;  the 
amount  of  urine  used,  therefore,  contains  this  amount  of  glucose, 
and  a  calculation  of  percentage  can  easily  be  made.  To  get  ac- 
curate results,  the  urine  should  be  quite  dilute,  and  if  the  quali- 
tative tests  indicate  considerable  sugar,  it  is  necessary  to  dilute  the 
liquid  to  five  or  even  ten  times  its  bulk  before  running  it  into  the 
Fehling's  solution.  This  dilution  must,  of  course,  be  allowed  for 
when  makinsT  the  final  calculation. 

Allen  recommends  the  following  test  for  cases  in  which  there 
may  be  doubt  as  to  the  presence  of  sugar.  Heat,  to  boiling,  about 
ten  cc.  of  Fehling's  solution,  and  add  a  nearly  equal  quantity  of 
the  urine  ;  heat  for  a  few  minutes,  and  then  set  aside  to  cool.  If 
no  turbidity  is  produced  as  the  liquid  cools,  the  urine  is  free  from 
sugar,  or,  at  most,  contains  less  than  -^-^  per  cent.  Fehling's  test 
can  also  be  used  for  peptone  and  propeptone.  It  gives  at  the 
point  of  contact  in  the  test-tube  a  rose-pink  or  purple  color. 

Boettgei-'s  Test. — Add  to  the  filtered  urine  about  half  its  vol- 
ume of  solution  of  caustic  soda  and  a  pinch  of  pure  bismuth  sub- 
nitrate,  and  boil  the  mixture.  Sugar  will  be  indicated  by  a  black 
precipitate.  If  sugar  is  not  present,  the  precipitate  will  be  white, 
or,  at  most,  somewhat  gray.  This  test  is  very  delicate  and  toler- 
ably free  from  fallacy.  Dark-colored  urines  of  high  gravity  may 
produce  a  gray  precipitate,  but  it  does  not  settle  so  rapidly  nor 
so  completely  to  the  bottom  of  the  tube.  A  pure  finely-powdered 
preparation  only  should  be  used  for  the  test. 

Recently  various  pastes  and  solid  pellets,  based  on  the  copper 
test,  have  been  suggested  for  ready  use,  as  by  Pavy  *  and  Piffard  ;t 
and  Neff I  has  introduced  some  cupric  pellets  which  may  be  easily 
employed  for  quantitative  analysis,  each  pellet  representing  accu- 


*  Clin.  Soc.  Transact.,  June,  1880;  Lond.  Lancet,  July  10, 1880. 
t  New  York  Medical  Record,  March  23,  1880. 
%  Medical  and  Surgical  Reporter,  April  16,  1880. 


694-  MEDICAL   DIAGNOSIS. 

ratoly  five  niilliorammes  of  o rape  sugar.  The  pellet  is  dissolved  in 
four  cc.  of  distilled  water  in  a  test-tube  ;  one  cc.  of  urine  is  diluted 
to  ten^vitli  distilled  water  ;  the  urine  thus  diluted  is  dropped  from 
a  burette  into  the  boiling  test-solution  until  the  eolor  is  entirely 
destroyed,  then  the  amount  used  is  read  off  from  the  burette. 

Other  forms  of  sugar,  such  as  sugar  of  milk,  may  be  found  in 
the  urine.  Sugar  of  milk  has  hitherto  been  met  with  only  in  the 
urine  of  lying-in  and  of  nursing  women. 

Acetone  is  a  substanee,  derived  from  sugar,  ^\•hiell  gives  to  dia- 
betic  urine  its  peculiar  sweetish  odor  :  its  clinical  significance  we 
shall  discuss  farther  on. 

Kalfe  gives  the  following  test  for  acetone.  About  four  cc.  (one 
drachm)  of  solution  of  caustic  soda  containing  a  gramme  (fifteen 
grains)  of  potassium  iodide  are  placed  in  a  test-tube  and  boiled. 
An  equal  volume  of  urine  is  then  poured  in  cautiously,  so  as  to 
float  on  the  surface  of  the  alkaline  liquid.  At  the  point  of  con- 
tact a  ring  of  phosphates  will  be  formed,  and  after  a  few  minutes 
colored  yellow  and  studded  wdth  crystals  of  iodoform.  Alcohol 
and  lactic  acid  also  give  this  result. 

Diacetio  acid',  a  body  somewhat  similar  to  acetone,  is  occasion- 
ally present  in  urine.  It  is  generally  recognized  by  the  red  color 
produced  by  solution  of  ferric  chloride. 

Inosite. — This  is  a  substance  belonging  to  the  group  of  sugars, 
and  occasionally  found  in  the  urine.  It  is  not  detected  in  health, 
and  is,  according  to  Cloetta,  the  observer  who  first  discovered  it 
in  urine,  associated  either  with  glucose  or  with  albumen,  but  it 
has  been  found  in  urine  containing  neither :  it  appears  to  be  de- 
rived from  the  glycogen  of  the  liver.  Inosuria  is  a  symptom 
rather  than  a  disease.*  The  characteristic  reaction  of  inosite  is 
exhibited  when  a  solution  of  the  substance  is  evaporated  with 
nitric  acid  nearly  to  dryness  on  platinum,  and  the  residue,  moist- 
ened with  a  little  ammonium  hydrate  and  a  solution  of  calcium 
chloride,  is  again  evaporated  to  dryness :  a  marked  rose-color 
appears, — which  does  not  happen  when  true  sugars  are  treated  in 
the  manner  described. 

The  presence  in  the  urine  of  the  blood-extractives  indicates 
merely  the  escape  of  blood-material,  and  proves  the  existence  of 

*  Gallois,  De  I'lnosurie,  1864. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       695 

congestion  or  inflammation  of  some  part  of  the  urinary  siirfac(;s. 
Rees  has  pointed  out*  tiiat  in  JBright's  disease  the  extractives  can 
be  found  in  the  urine  before  albumen  is  met  with,  and  also  that 
they  exist  after  the  albumen  has  disappeared, — thus  warning  us, 
on  the  one  hand,  of  the  approaeh  of  albuminuria,  and,  on  the 
other,  against  too  early  a  belief  in  convalescence;  for,  as  he  justly 
observes,  so  long  as  the  blood  is  losing  its  extractives  so  long  is 
the  patient  in  peril.  The  presence  of  the  extractives  also  enables 
us  to  diagnosticate  nephritic  irritation  from  renal  calculus  before 
albumen,  blood,  or  pus  has  appeared.  It  is  highly  probable  that 
extractives  will  be  found  preceding  albumen  in  urine  in  most  cases. 
To  the  delicate  test  by  guaiacum  for  the  crystalloids  of  the  blood, 
which  has  been  used  to  detect  this  prealbuminuric  stage,  we  shall 
presently  more  particularly  refer. 

Albumen. — Urine  may  be  albuminous  from  admixture  with 
blood  or  pus,  or  from  transudation  of  the  albumen  of  the  serum 
of  the  blood  through  the  walls  of  the  vessels  of  the  kidneys. 
The  forms  of  albumen  in  the  urine  are  chiefly  serum -albumen, 
paraglobulin,  and  globulin,  though  peptones  and  albumoses  are 
also  found.  Sometimes  the  albumen  appears  only  for  a  short  time 
in  the  urine;  at  other  times  it  is  permanent;  and  in  accordance  with 
the  length  of  its  stay  its  significance  varies.  It  has  been  thought 
to  be  present  in  small  quantities  in  healthy  urine,  as  is  also  stated 
of  sugar  and  of  oxalic  acid,  but  the  evidence  of  this  is  very  uncer- 
tain.f  But  let  us  here  examine  the  tests  announcing  the  presence 
of  the  foreign  substance. 

There  are  several  methods  enabling  us  to  ascertain  the  occur- 
rence of  albumen,  all  dependent  on  coagulation.  Of  these,  the 
chief  are  : 

Heat; 

Nitric  acid; 

Picric  acid; 

Glacial  phosphoric  acid. 

Heat. — Albumen  is  rendered  insoluble  by  a  heat  of  about 
150°  F.  (65°  C).     A  test-tube  should  be  about  one-third  filled 


*  Guy's  Hospital  Keports,  3d  Series,  vol.  xiv.  p.  431. 

t  See  Posner,  Virchow's  Archiv,  Bd.  Ixxix.  ;  and  Senator,  Die  Albuminurie 
im  gesunden  und  kranken  Zustande,  Beriin,  1882. 


606  MEDICAL    D^AG^•OSIS. 

with  the  urine,  heated  until  the  licpiid  boils,  and  then  a  few  drops 
of.  nitric  or  aeetie  aeid  should  be  added.  If  the  precipitate  re- 
mains, albumen  is  present.  A  precipitate  produced  by  boiling 
but  dissolved  bv  the  acid  is  due  to  phosphates,  and  should  be 
disregarded. 

Nitnc  Acid,  Heller's  Test. — Fifteen  drops  of  commercial  nitric 
acid  are  jjlaced  in  a  somewhat  narrow  test-tube,  and  some  urine 
poured  slowly  down  upon  it,  the  tube  being  considerably  inclined. 
Another  method  is  to  put  the  urine  in  first  and  introduce  the  acid 
by  means  of  a  pipette,  so  as  to  form  a  clear  layer  at  the  bottom  of 
the  tube.  A  white  ring  forms  at  the  point  of  contact.  Urine  in 
which  this  test  does  not  show  albumen  may,  for  practical  pur- 
poses, be  regarded  as  not  containing  it. 

Urine  rich  in  urea  sometimes  forms  a  precipitate  of  urea  nitrate. 
It  may  be  distinguished  from  albumen  by  its  crystalline  character, 
especially  after  standing  a  few  hours,  and  by  its  solubility  when 
the  liquid  is  warmed.  Excess  of  urates  may  also  produce  a  pre- 
cipitate that  might  be  mistaken  for  albumen,  but  the  ring  is  irreg- 
ular and  will  in  a  few  hours  become  distinctly  crystalline  and  can 
be  easily  determined  under  the  microscope. 

Resinous  bodies  administered  as  medicines  are  occasionally  ex- 
creted by  the  urine,  and  are  precipitated  by  the  addition  of  nitric 
acid.  They  may  generally  be  recognized  and  distinguished  from 
albumen  by  their  strong  odor  and  by  their  solubility  in  alcohol. 

According  to  Hofmanu  and  Ultzmann,  the  precipitate  produced 
by  nitric  acid  in  the  cold  may  be  taken  as  a  rough  quantitative 
approximation.  If  the  white  zone  has  a  depth  of  from  one-tenth 
to  one-eighth  of  an  inch,  and  appears  clearly  defined  only  when 
placed  against  a  dark  ground,  the  amount  of  albumen  is  less  than 
one-half  of  one  per  cent. ;  if  the  zone  is  somewhat  deeper,  and 
visible  without  a  dark  ground,  the  amount  of  albumen  is  about 
one-half  per  cent. ;  while  if  the  precipitate  is  flocculent  and  sep- 
arates in  lumps,  it  amounts  to  over  one  per  cent.  In  urine  con- 
taining: alkaline  carbonates  an  effervescence  will  occur  when  any 
acid  is  added,  but  this  will  soon  cease  and  the  coagulum  will  be 
formed. 

Sometimes  urine  is  encountered  on  which  neither  the  heat  nor 
the  acid  test  yields  the  customary  result.  This  is  owing  to  its 
containing  a  modified  form  of  albumen.     Such  a  case  was  pub- 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       607 

lished  by  Bence  Jones.*  No  coagulation  was  produced  by  heat, 
and  none  by  nitric  acid,  unless  the  urine  was  subsequently  heated 
and  permitted  to  cool.  The  solid  that  formed  on  cooling  dis- 
appeared on  heating.  The  patient  was  laboring  under  mollities 
ossium,  Basham  recommends  the  tincture  of  galls  as  a  test  for 
this  modified  form  of  albumen.  Scherer,  too,  has  met  with  a 
form  of  albumen  perceptible  from  the  solution  containing  it  by 
alcohol,  but  not  by  heat;  boiling  causing  a  mere  turbidity. 
Gowersf  notes  a  peculiar  kind  of  albumen  in  the  urine  that  is 
soluble  at  the  temperature  of  boiling  water,  heat  and  nitric  acid 
producing  no  precipitate ;  nor  does  alcohol  in  moderate  quantity ; 
while  a  moderate  quantity  of  nitric  acid  throws  down  an  abun- 
dant sediment  in  cold  urine.  There  are  several  albuminous  forms 
in  urine  in  different  conditions, — some,  like  the  peptones,  the  re- 
sult of  incomplete  digestion ;  others,  like  paraglobulin,  derived 
from  the  blood.J  Senator  has  taught  us  to  view  both  peptones 
and  albumoses  as  due  to  altered  blood-composition. 

Glacial  jjliospliorio  acid  (metaphosphoric  acid)  is  usually  seen 
in  the  form  of  slender  sticks  or  glass-like  masses.  It  is  used  as 
a  test  by  simply  placing  a  piece  about  the  size  of  a  cherry-stone 
in  cold  (filtered)  urine  and  allowing  it  to  remain  perfectly  quiet 
for  a  few  moments.  The  acid  dissolves  slowly,  forming  a  clear 
syrupy  liquid,  in  which  the  slightest  trace  of  albumen  will  be 
seen  as  a  cloud.  The  cloud  can  be  made  more  apparent  by 
slightly  shaking  the  test-tube.  No  difficulty  will  be  found  in 
distinguishing  between  the  syrupy  liquid  formed  by  the  solution 
of  the  acid  and  the  actual  precipitate  of  albumen.  The  acid 
should  be  kept  in  a  closely-stopped  bottle.  It  does  not  produce 
any  color  with  the  urine.     Heat  must  not  be  used. 

Picric  acid  occurs  in  the  form  of  bright  yellow  crystals,  which 
are  used  as  a  test  by  simply  dropping  them  into  the  filtered  urine, 
in  falling  through  which  they  form  a  coagulum.  The  saturated 
solution  may  also  be  employed  in  the  manner  of  the  contact 
•nitric  acid  test.  Picric  acid  makes  a  very  delicate  test,  but  shows 
about  the  same  fallacies  as  the  other  acid  tests.     It  also  forms 

*  Philosophical  Transactions  for  1848. 
t  Lancet,  July,  1878. 

X  Senator,  Virchow's  Archiv,  Bd.  Ix.,  1879 ;  Brunton  and  Power,  St.  Barth. 
Hosp.  Kep.,  1877 ;  ISTeubauer  and  Vogel,  op.  cit,  7th  ed.,  p.  384,  Amer.  transl. 


698  MEDICAL   DIAGNOSIS. 

a  slight  procijiitatc  with  mucus,  staius  the  skin  yollow,  and  is 
somewhat  explosive. 

As  regards  the  tests  for  these  different  forms  of  albumen,  it 
may  here  in  general  terms  be  stated  that  peptone  and  albumose 
are  not  coagulated  bv  the  heat  test.  But  in  urine  acidulated 
by  a  few  drops  of  acetic  acid,  and  then  treated  by  a  solution  of 
potassium  ferrocyanide,  a  white  cloud  indicates  these — or  rather 
the  latter — albuminous  substances,  Avhich  are  distinct  from  the 
commonly  present  forms  of  albumen,  the  scrum-albumen  especially, 
for  which  the  heat  and  nitric  acid  tests  are  employed.  Albumose 
is  also  preci})itated  in  cold  acidulated  urine  by  nitric  acid,  by 
sodium  chloride,  and  by  magnesi-imi  sul])hatc ;  the  deposit  dis- 
appears on  heating.  Peptone  itself,  much  more  often  met  with 
in  urine  than  albumose,  is  not  jirecipitatcd  by  the  acetic  acid  and 
ferrocyanide  test  just  mentioned,  but  by  tannin,  by  corrosive  subli- 
mate, and  by  picric  acid.  Peptonuria  is  common  in  phosphorus- 
poisoning,  and  during  the  absorption  of  exudations  containing 
peiDtone,  as  in  pleurisy,  in  pneumonia,  in  rheumatism.  Globulin 
may  not  be  detected  by  the  ordinary  tests,  but  magnesium  sulphate 
precipitates  it. 

The  following  are  some  of  the  tests. 

One  drachm  of  Fchling's  solution  is  placed  in  a  test-tube  and 
a  little  of  the  urine  filtered  into  it.  At  the  point  of  contact  the 
phosphates  form  a  precipitate,  and  the  peptones  produce  a  rose- 
colored  halo  above.  If  albumen  is  also  present,  the  halo  will  be 
purple. 

Of  the  proteid  bodies  usually  occurring  in  urine,  all  but  the 
peptones  are  precipitated  by  saturating  the  liquid  with  ammonium 
suljjhate.*  This  is  easily  done  by  adding  the  powdered  material 
until  no  more  is  dissolved.  Ovall:)umen,  serum-albumen,  para- 
globulin,  and  the  albumoses  are  separated,  and  may  be  collected  on 
a  filter.  To  detect  peptones,  the  filtrate  should  be  treated  with 
a  drop  of  a  solution  of  copper  sulphate  and  then  considerable 
caustic  soda  added.     A  rose-red  color  indicates  the  peptones. 

To  distinguish  the  different  proteids  thrown  down  by  ammo- 
nium sulphate,  the  precipitate  is  washed  while  on  the  filter  with 
some  solution  of  ammonium  sulphate  and  then  dissolved  by  the 

*  Martin,  Brit.  Mod.  .Journ.,  April  21, 


THE   URINE,  AND    DISEASES   OF  THE   URINARY   ORGANS,       099 

addition  of  distilled  water.  Ovalbumcn  is  coagulated  by  etli(!r, 
serum-albumen  is  not.  Paraglobulin  and  albumosc  arc  precipi- 
tated by  saturating  the  liquid  with  magnesium  sulphate.  By 
collecting  the  precipitate  so  formed,  adding  water  to  it,  boiling, 
and  acidulating  with  a  few  drops  of  acetic  acid,  albumose  will 
dissolve,  but  paraglobulin  will  not. 

Mucin  is  very  often  present  in  normal  urine,  and  may  become 
abundant  in  irritated  conditions  of  the  genito-urinary  organs.  It 
is  precipitated  by  strong  acids  and  alcohol,  but  not  by  boiling. 
If  to  a  urine  containing  much  mucin  three  volumes  of  strong 
alcohol  be  added,  all  the  mucin  and  albumen  will  be  precipitated. 
After  standing  for  a  few  hours,  the  liquid  should  be  filtered,  and 
the  precipitate  washed  M^ith  alcohol,  treated  with  warm  water, 
and  again  filtered ;  the  filtrate  will  contain  the  mucin,  which  will 
respond  to  tests  with  strong  acids. 

It  is  often  of  service  to  determine  the  exact  amount  of  albumen 
voided  with  the  urine.  This  may  be  accomplished  by  adding  a 
small  quantity  of  acetic  acid  to  a  weighed  quantity  of  urine,  which 
is  then  to  be  boiled.  The  precipitate  is  collected  on  a  filter, 
dried,  and  weighed.  For  approximate  estimation,  see  under  nitric 
acid  test. 

Blood. — The  passage  of  blood  with  the  urine  constitutes  hsema- 
turia.  The  urine  is  of  a  red  color,  or  of  a  more  or  less  dingy  or 
smoky  hue,  and  deposits,  on  standing,  a  reddish-brown  or  a  dark 
coffee-ground  sediment.  If  much  blood  be  present,  small,  irregu- 
lar masses  are  seen  at  the  bottom  of  the  vessel. 

The  appearance  of  urine  containing  blood  is  therefore  not  uni- 
form. The  diagnosis  is  at  once  rendered  certain  by  the  use  of 
the  microscope.  And  only  by  this  means  can  it  be  rendered  cer- 
tain ;  for  urine  may  be  red  or  black,  from  the  admixture  of  various 
pigments  derived  from  substances  swallowed  as  food  or  medicine 
or  belonging  to  the  economy.  Thus,  beet-root,  some  kinds  of 
strawberries,  logwood,  and  rhubarb  impart  a  deep  red  color,  which 
may  be  the  cause  of  groundless  alarms ;  or  urine  deeply  tinged 
with  bile,  or  discolored  by  fever,  may  be  thought  to  signify  the 
occurrence  of  hemorrhage  from  the  urinary  passages. 

The  chemical  tests  for  blood  are,  on  the  whole,  inferior  to  the 
microscopic  examination.  We  may  have  sometimes  to  resort  to 
them.     I  have  found  a  rough  test  in  the  addition  of  carbolic  acid. 


7C0  MEDICAL    DIAGNOSIS. 

Nvliich  not  only  coagulates  the  albumen,  but  also  ehangcs  the  color 
of  the  tluid.  It  does  not  })roiluee  the  same  peculiar  reddish  tinge 
with  bile,  or,  so  far  as  I  have  tried,  with  any  other  substance.  The 
gnaiacum  test  is  very  accurate.  It  is  said  by  Mahomed  to  detect 
infinitesimal  traces  of  blood,  or  rather  its  characteristic  crystalloids, 
M'hen  neither  the  microscope  nor  the  spectroscope  nor  the  nitric 
acid  test  for  albumen  affords  any  indication  of  their  presence. 
It  is  especially  valuable  in  the  recognition  of  the  prcalbumi- 
nuric  stage  of  Bright's  disease,  in  which  luvmoglobin  appears  in 
the  urine  before  albumen.*  The  test,  as  modified  by  Stevenson, 
consists  in  adding  to  a  few  drops  of  urine  in  a  small  test-tube  a 
drop  of  tincture  of  guaiacum  and  then  a  few  drops  of  ozonic  ether. 
The  mixture  is  agitated,  and  as  the  ether  collects  at  the  top  it  carries 
with  it  the  blue  color  produced  by  the  hremoglobin,  leaving  the 
urine  colorless  below.  If  saliva  or  a  salt  of  iodine  be  present,  the 
test  is  fallacious.  The  spectroscope  affords  a  very  delicate  test. 
The  characteristic  bands  of  haemoglobin  of  yellow  and  green  are 
seen  between  D  and  E.  If  the  hremoglobin  be  in  a  state  of 
destruction  or  reduction,  only  one  broad  band  appears. 

But  the  microscope,  as  already  stated,  is  the  means  most  em- 
ployed. The  corpuscles  we  detect  with  it  are  not  always  of  uni- 
form appearance,  yet  they  are  never  collected  in  rouleaux.  But, 
after  having  found  blood-corpuscles  to  indicate  the  true  nature  of 
the  changed  hue  of  the  excretion,  the  cpiestions  remain  to  be  solved, 
at  what  point  has  the  blood  been  poured  out  ?  Is  it  really  from 
the  urinary  organs?  and  if  it  be  from  them,  whence? — from  the 
kidneys,  from  the  bladder,  or  from  some  other  portion  of  the  tract? 
Again,  what  morbid  state  lies  at  the  root  of  the  hemorrhage  ? 

Now,  the  first  of  these  questions  must  always  be  answered  at 
the  onset.  Blood  may  flow  from  the  vagina  or  uterus  and  become 
mixed  with  the  urinary  secretion,  or  it  may  have  been  added  for 
purposes  of  deception.  In  the  former  case,  a  careful  inquiry  into 
the  state  of  these  organs,  or,  if  necessary,  a  digital  examination, 
will  eliminate  the  source  of  error ;  in  the  latter,  drawing  off  the 
urine  by  the  catheter  will  detect  the  imposture.  When  we  have 
fully  satisfied  ourselves  that  the  blood  is  derived  from  the  urinary 
organs,  the  next  point  to  be  ascertained — and  clinically  its  im- 

*  Medico-Cliirurfrical  Tran^iictions,  1874. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       701 

portance  cannot  be  overrated — is,  whether  it  proceeds  from  tlie 
kidney  or  from  the  bladder.  To  determine  this,  we  have  ntjt  only 
to  study  the  cliaracter  of  the  fluid  excreted,  but  also  to  investigate 
closely  all  the  conditions  of  the  accident. 

If  the  blood  come  from  the  bladder,  it  is  not  equally  diffused 
througli  the  urine ;  the  fluid  discharged  is  at  first  clear  or  nearly 
so,  but  at  the  end  of  the  act  of  micturition  is  much  more  deeply 
colored,  or  pure  blood,  in  a  liquid  form  or  in  clots,  is  voided. 
Then,  too,  there  is  usually  pain  over  the  bladder,  with  a  frequent 
desire  to  pass  water,  aud  a  stoppage  in  doing  so. 

AVhen  the  blood  is  derived  from  the  kidney,  we  discover,  on 
the  one  hand,  pain  in  the  lumbar  region,  and  other  symptoms 
pointing  to  the  affected  organ,  the  existence  of  albumen  in  con- 
siderable quantities  in  the  urine,  or  the  passage  of  gravel.  Clots 
are  not  encountered  in  renal  hemorrhage,  except  when  the  blood 
coagulates  in  the  infundibulum  or  the  ureter  and  is  gradually 
forced  downward.  Such  clots  are  of  a  whitish  color,  and  generally 
of  cylindrical  shape.  In  their  passage  toward  the  bladder  and  out 
of  the  urethra  they  become  often  the  source  of  distressing  pain. 
They  are  very  significant,  yet  they  are  not  absolutely  pathogno- 
monic of  renal  hemorrhage ;  for  coagula  formed  in  the  bladder 
may  be  retained  there  for  some  time,  and  lose  their  color  before 
they  are  expelled.  Sometimes  we  meet  with  little  solid  or  gelati- 
nous fibrinous  coagula  which  bespeak  simply  localized  fibrinous 
exudation  from  some  part  of  the  urinary  passages. 

Aid  in  diagnosis  may  be  derived  from  the  study  of  the  shape 
of  the  clots,  which  for  this  purpose  should  be  floated  out  in  water. 
According  to  Hilton,*  they  will  oftentimes  be  exact  moulds  or  casts 
of  the  cavity  in  which  the  blood  was  effused.  Thus,  coagula 
formed  within  the  bladder  have  a  somewhat  irregular,  circular 
outline,  and  are  flattened  in  shape,  with  bevelled  and  serrated 
edges.  The  use  of  the  microscope,  furthermore,  is  very  valuable 
in  the  differential  diagnosis.  The  epithelium  which  is  mixed  with 
the  blood  from  the  kidney  is  not  flat  and  in  scales,  like  that  from 
the  bladder,  but  small  and  more  or  less  round  or  columnar ;  nor 
are  there  fibrinous  shreds  to  be  seen.  Hofmann  and  Ultzmann 
direct  attention  to  the  various  size  of  the  corpuscles  as  significant 

*  Guy's  Hospital  Keports,  3d  Series,  vol.  xiii.  p.  19  ei  seq. 


702  MEDICAL   DIAGNOSIS. 

of  the  luL'maturia  which  atteiuls  paivncliyniatous  affcctious  of  the 
kidney ;  besides  the  normal  disk-formed  corpuscles,  which  are, 
howevei:,  frequently  quite  colorless,  very  small,  even  dust-like 
blood-corpuscles  are  met  with.  Sometimes  the  blood-globules 
are  seen  to  be  collected  on  casts  that  have  been  moulded  within 
the  renal  tubes.  These  blood-casts  warrant  an  absolute  conclusion 
as  to  the  source  of  the  hemorrhage.  But  they  do  not  always 
occur ;  and  their  absence,  therefore,  is  not  so  valuable  a  proof  as 
their  presence. 

Although,  then,  there  is  no  one  luicquivocal  sign  of  either  renal 
or  vesical  hemorrhage,  we  may  generally  arrive  at  a  correct  knowl- 
edge of  the  source  whence  the  blood  proceeds.  In  perplexing 
cases  we  sliould  obtain  specimens  of  urine  for  examination  in  the 
manner  above  recommended.  The  cause  of  the  bleeding  cannot  be 
determined  save  by  careful  analysis  of  the  group  of  symptoms. 

Renal  hsematiiria. — When  of  renal  origin,  the  hseraaturia  is 
often  due  to  congestion  or  an  acute  parenchymatous  inflammation 
of  the  kidneys  in  infectious  maladies,  such  as  in  scarlatina,  small- 
pox, malignant  measles,  and  typhus.  Here  we  have  the  history 
of  the  malady,  and  the  presence  of  tube-casts  and  of  a  consider- 
able amount  of  albumen  in  the  urine,  to  explain  the  meaning  of 
the  hemorrhage.  The  blood  is  derived  from  the  engorged  and 
ruptured  ]\Ialpighian  corpuscles.  But  as  regards  the  large  amount 
of  albumen  present,  we  must  not  lay  too  much  stress  on  this  as  in- 
dicating marked  kidney  implication.  I  have  known  it  to  happen 
where  the  kidneys  were  not  affected.  Irritant  medicines,  too, 
such  as  turpentine  and  eantharides,  may  also  cause  congestion  and 
bloody  urine;  and  so  do  strains  and  blows  on  the  back.  In  all 
these  varied  circumstances,  a  careful  survey  of  the  history  and  the 
symptoms  will  establish  the  diagnosis. 

Renal  hsematuria  of  chronic  character  is  generally  due  to  cancer 
of  the  kidney  ;  to  cystic  degeneration ;  to  ulceration  Avithin  the 
pelvis  of  the  organ  ;  or  to  irritation,  with  or  without  ulceration, 
set  up  by  a  eak-ulus.  In  the  first  of  these  affections  there  is  noth- 
iug  in  the  urine  to  point  out  the  source  of  the  hsematuria  until  the 
disease  is  far  advanced,  when  pus,  and  sometimes  disorganized 
cancerous  tissue,  may  be  discerned  in  the  sediment.  The  mani- 
festations of  cystic  degeneration  are  uncertain  unless  we  can  detect 
a  large  tumor ;  and  the  signs  of  a  non-calculous  pyelitis  are  not 


THE   URINE,  AND   DISEASES   OF   THE   URINARY   ORGANS.      703 

sufficiently  definite  to  enable  us  to  distinguish  this  rare  malady 
with  anything  like  accuracy.  The  existence  of  a  calculus — the 
most  common  of  the  agents  producing  chronic  hematuria — is 
indicated  as  the  source  of  the  hemorrhage  by  localized  pain,  and 
by  the  bleeding  having  followed  active  exertion,  or  a  jar  of  the 
body  from  a  fall,  and  by  its  recurring  from  time  to  time  under 
circumstances  like  those  just  mentioned,  favorable  to  the  disturb- 
ance of  a  calculus  lodged  in  the  kidney.  The  presumption  of  this 
being  the  reason  of  the  repeated  bleeding  is  converted  almost  into 
certainty  if  on  any  occasion  a  stony  concretion  have  been  expelled. 
Simon  has  catheterized  the  ureters  and  thus  determined  renal  cal- 
culi ;  but  this  is  not  a  procedure  easy  to  imitate. 

Under  the  name  of  intermittent  hsematuria,  or  paroxysmal  hsema- 
tinuria  or  hsemoglobinuria,  has  been  described  a  disease  which 
differs  from  ordinary  renal  hemorrhage ;  the  urine,  although 
coagulable  by  heat  and  nitric  acid,  exhibits  very  few  or  no  blood- 
corpuscles,  the  coloring-matter  is  not  deposited  on  standing,  there 
is  blood  dissolution,  and  the  blood  coloring-matter  only  is  found 
in  the  urine.  We  may  use  the  guaiacum  test  to  develop  the 
presence  of  the  dissolved  haemoglobin ;  the  hsemin  crystals  of 
Teichmann  can  be  produced,  and  with  the  spectroscope  we  find 
the  oxyhsemoglobin  bands  between  D  and  E,  occasionally  also  the 
methsemoglobin  bands  in  the  red.  The  urine  voided  is  generally 
of  a  deep  blood-color,  and  within  an  hour  or  two,  perhaps,  changes 
suddenly  to  a  pale  straw-color.  It  shows  an  increased  proportion 
of  urea.  According  to  Greenhow,*  crystals  of  calcium  oxalate 
are  constantly  passed  during  a  paroxysm,  and  are  absent  at  other 
times.  The  affection  is  unattended  by  any  permanent  lesion  of  the 
kidneys.  It  is  paroxysmal  in  form,  and  is  not  of  malarious 
origin. t  The  disease  is  ushered  in  by  a  chill,  A¥hich  is  followed 
by  only  an  imperfect  hot  stage,  and  more  rarely  by  sweating;  in 

*  Transactions  of  Clinical  Society,  1868,  vol.  i. 

t  See  Greenhow,  loc.  cit.;  also  Pavy,  Transact.  Path.  Soc.  Lond.,  vol.  xviii. ; 
Druitt,  Medical  Times  and  Gazette,  vol.  i.,  1873;  Lichtheim,  in  Yolkmann's 
Sammlung  Klin.  Vortrage,  1878,  No.  134;  Fleischer,  Berlin.  Klin.  Wo- 
chenschr.,  No.  47,  1881  ;  A.  Baines,  Canada  Pract.,  1886,  xi. ;  E.  K.  Fornet, 
Pest.  Med.-Chir.  Presse,  1886,  xxii.  ;  W.  P.  Herringham,  St.  Barth.  Hosp.  Eep., 
1886,  xxii.;  Lehzen,  Zeitschr.  f.  Klin.  Med.,  Berlin,  1887,  xii. ;  W.  McVie, 
Med.  Press  and  Circular,  1887,  N.  S.,  xliv.  ;  Bamberger,  Deutsche  Med.  Zeitung, 
1887  ;  Senator,  ib.,  1887,  and  A.  E.  L.  Charpentier,  Lancet,  1888,  ii. 


704  MEDICAL   DIAGNOSIS. 

some  instancos  iinnKKleratc  yawning-  and  stivtchiiiLi"  of  the  limbs 
are  tlie  initiatory  syniptonis,  and  tirtiearia  and  loi'al  lyanotie  aj)- 
pearances  and  great  tliirst  are  observed.  Tlie  temperature  may  be 
that  of  health,  or  may  rise  to  be  high.  Transitory  albuminuria 
precedes  or  is  occasionally  associated  ;  between  the  attacks  the  urine 
is  normal.  In  the  blood  during  the  attack  a  marked  diminution 
of  red  corpuscles  is  observed,  as  well  as  masses  of  granules  and 
spindle-shaped  bodies  and  other  products  of  destructive  change  ; 
and  it  is  very  likely,  as  Ponfick  maintains,  that  the  blood  condi- 
tion is  primai-y  and  the  ha?moglobinuria  secondary.  The  etiology 
of  the  disease  is  unknown.  It  often  hai)pens  in  syphilitic  sub- 
jects. In  those  predisposed,  brain-worry  brings  on  attacks ;  rest 
and  food  may  prevent  them.  But  the  influence  of  cold  seems  to 
be  the  most  potent  cause.*  By  many  it  is  held  that  the  disease  is 
due  to  a  morbid  action  of  the  liver. 

There  is  an  intermittent  ha}maturia  wliich  is  malarial.  This 
malarial  hsemaiuna  has  been  frequently  observed  in  our  Southern 
States,  especially  in  Florida,  Louisiana,  and  Texas,  and  in  the  East 
and  West  Indies.  The  hrematuria  may  occur  in  daily  parox}-sms, 
or  at  longer  but  regular  intervals.  The  bleeding  sets  in  suddenly, 
but  the  urine  soon  clears  up,  though  in  some  instances  it  remains 
persistently  bloody.  The  urine  is  albuminous,  contains  casts, 
hsemoglobin,  and  generally  only  few  blood-disks ;  it  shows,  then, 
a  hemoglobinuria  rather  than  a  hrematuria.  The  attacks  are 
mostly  preceded  by  coldness  of  the  extremities ;  some  elevation 
of  temperature  may  follow.  AVhen  there  are  distinct  fever  and 
yellowness  of  skin,  the  hemorrhage  from  the  kidney  forms  part 
of  the  disease  known  as  hemorrhagic  malarial  fever.  INIalarial 
haematuria  is  more  common  in  men  than  in  women. "f     It  differs 


*  Rosenbach,  Berlin.  Klin.  Wodien.schr.,  1880;  IMaekcnzie,  Lancet,  Feb.  1884. 

t  Tyson,  System  of  Pract.  ^Sled.  by  Amer.  Authors,  vol.  iv.  ;  sec  also  M.  J. 
Alexander,  Mississippi  Valley  ]\Ied.  Month.,  Memphis,  1886,  vi.  ;  S.  H.  Brown, 
ib. ;  R.  H.  Day,  New  Orleans  Med.  and  Surjj.  Journ.,  1886-87,  N.  S.,  xiv. ; 
Transact.  Louisiana  Med.  Soc,  New  Orleans,  1886,  viii.  ;  J.  E.  Stubbert,  Med. 
and  Surg.  Reporter,  1886,  Iv.  ;  .J.  A.  Stamps,  ib. ;  C.  C.  Thornton,  ib. ;  J.  A. 
Abney,  Texas  Cour.-Rec.  Med.,  1886-87,  iv. ;  W.  P.  Hart,  Transact.  Med.  Soc. 
Arkansas,  Little  Rock,  1887 ;  A.  N.  Perkins,  Daniel's  Texas  Medical  Journal, 
1887-88,  iii. ;  Victor  A.  Rousseau,  Bordeaux,  1887  ;  W.  O'Daniel,  Tran.sact.  In- 
ternat.  Med.  Con";.,  Washington,  1887,  i.  ;  Baker,  Prize  E,ssay,  North  Carolina 
Med.  Journ.,  1887;    J.  A.  Stamps,  Therap.  Gaz.,  1888,  3d  S.,  iv. 


THE   URINE,  AND   DISEASES   OF   THE   URINARY   ORGANS.      705 

from  ordinary  paroxysmal  lisematuria  above  described  in  the 
strong  malarial  history,  in  the  greater  regularity  of  the  parox- 
ysms, and  in  the  influence  quinine  generally  exerts  on  them. 

There  is  also  a  form  of  hematuria  which  is  endemic  and  de- 
pends upon  the  presence  of  a  parasite  (Bilharzia  hgematobia).  It 
prevails  in  the  Mauritius,  certain  parts  of  Cape  Colony,  Natal, 
Egypt,  and  Brazil.  The  parasite  inhabits  mainly  the  small  ves- 
sels of  the  mucous  membrane  of  the  urinary  passages  and  the 
kidneys,  and  it  gains  chiefly  access  to  these  parts  during  the  act 
of  bathing  in  rivers.  Persons  aflected  with  the  Bilharzia  hsema- 
tobia  are  often  observed  to  pass  small  renal  calculi  of  calcium 
oxalate  having  for  their  nuclei  the  ova  of  this  parasite  ;*  they 
may  also  present  chylous  urine.  A  similar  parasitic  hsematuria, 
due  to  the  Filaria  sanguinis  hominis,  is  met  with  in  India. 

Further,  there  is  a  hsematuria  peculiar  to  infants. .  This  has 
been  described  by  Parrot,  f  under  the  name  of  renal  tubal  hsema- 
turia, and  is  characterized  by  haematuria  and  the  accumulation  in 
the  tubules  of  the  kidney  of  the  red  globules  of  the  blood,  and 
by  a  bronze  discoloration  of  the  skin,  and  cephalic  symptoms. 

Besides  these  causes,  renal  hemorrhage  may  occur  from  rupture 
of  the  kidney,  of  which  it  is  the  most  prominent  sign.  It  may 
also  result  from  an  altered  state  of  the  blood,  as  in  purpura  and 
in  scurvy ;  or  we  may  find  hsemoglobinuria  in  these  states.  We 
also  find  the  dissolved  blood  in  the  urine  after  extensive  burns 
and  excessive  doses  of  potassium  chlorate. 

Vesical  hsematuria. — One  source  to  which  this  may  be  owing  is 
a  congestion  of  the  bladder,  as  witnessed  in  fevers  of  a  low  type ; 
another  is  irritant  diuretics ;  another  is  blood-effusion  from  pur- 
pura or  the  hemorrhagic  diathesis.  Yet  another  is  inflammation, 
whether  acute  or  chronic,  and  whether  of  traumatic  origin  or 
brought  on  by  a  stone.  In  most  of  these  contingencies  the  his- 
tory of  the  case  and  the  local  symptoms  establish  the  diagnostic 
distinctions ;  in  arriving  at  which  we  are  often  materially  aided 
by  the  introduction  of  a  sound  into  the  bladder. 

Hemorrhage  from  the  bladder,  dependent  upon  tumor  or  malig- 

*  Geo.  Harley,  Med.-Chir.  Transact.,  vol.  xlvii.  p.  55,  and  vol.  lii.  p.  379; 
Handford,  Brit.  Med.  Journ.,  1887;  Allen,  London  Practitioner,  April,  1888, 
and  Hill,  London  Lancet,  May,  1888. 

f  Archives  de  Physiologic,  Sept.  1873. 

45 


706  MEDICAL   DIAGNOSIS 

nant  growths  on  its  mucous  coat,  is  usually  attended  with  pain, 
with  a  constant  desire  to  empty  the  viscus,  and  with  considerable 
emaciation  and  a  general  cachectic  condition.  The  fluid  which  is 
passed  contains  pus,  and,  as  the  malady  advances,  from  time  to 
time  large  quantities  of  blood.  Yet  the  appearance  of  the  blood 
in  the  excretion  may  be  the  first  sign  of  disturbance.* 

Vesical  hannaturia,  more  frequently  than  renal,  occurs  as  a 
vicarious  discharge.  Persons  who  are  subject  to  bleeding  piles 
lose  blood  occasionally  from  the  bladder  instead  of  from  the  rec- 
tum. But,  in  obscure  cases  of  this  kind,  before  arriving  at  a 
conclusion  it  is  necessary  to  bear  in  mind  that  true  vesical  hemor- 
rhoids are  not  uncommon. 

Blood  may  be  discharged  from  other  parts  of  the  urinary  appa- 
ratus ;  it  may  come  from  the  jyrostate  gland  or  from  the  urethra. 
Now,  in  either  case  the  bleeding  is  usually  profuse,  and  large 
quantities  of  blood  are  passed  pure,  or  unmixed  with  urine.  Be- 
sides, there  are  local  signs  of  disease  of  these  parts,  furnishing 
important  points  of  discrimination. 

Such,  then,  are  the  various  conditions  under  which  hsematuria 
may  be  noticed.  As  regards  its  gravity,  it  is  evident  that  this 
depends  less  upon  the  hemorrhage  itself  than  uj^on  the  disorder 
of  which  the  hemorrhage  is  a  symptom.  The  flow  of  blood  in 
itself  is  very  rarely  fatal.  One  of  the  worst  consequences  it  may 
entail  is  the  retention  of  a  clot  which  serves  as  a  nucleus  for  the 
formation  of  a  calculus. 

Pus. — Urine  containing  pus  deposits  an  opaque  creamy  sedi- 
ment or  a  glairy  mass,  is  generally  alkaline,  and  always  slightly 
albuminous.  If  the  deposit  be  agitated  with  a  strong  solution 
of  caustic  soda  it  becomes  gelatinous.  This  is  the  chemical  test 
for  pus.  But  it  is  a  clumsy  one,  compared  with  the  rapid  and 
absolute  diagnosis  of  the  pus-corpuscles  by  means  of  the  micro- 
scope ;  this  is  especially  valuable  where  the  amount  of  pus  is 
very  small. 

A  deposit  of  phosphates  may  be  mistaken  for  pus;  a  few  drops 
of  acetic  acid  clear  it  up,  but  do  not  influence  pus.  Sometimes  a 
large  amount  of  mucus  is  mixed  with  the  purulent  sediment,  or  a 
deposit  due  wholly  to  the  former  ingredient  is  so  considerable  that 

*  See  case  by  Todd,  Case  XI.,  Lectures  on  Urinary  Diseases. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       707 

it  is  mistaken  for  pus.  Yet  the  mucous  deposit  shows  distinct 
points  of  difference:  it  is  less  dense,  and  collects  more  in  clouds 
at  the  bottom  of  the  vessel ;  and  it  docs  not  under  any  test  show 
albumen.  Again,  the  microscope  is  a  valuable  means  of  discrimi- 
nation. In  place  of  pus-corpuscles,  quantities  of  epithelium  are 
always  seen  to  be  entangled  in  the  transparent  mucus,  and  the 

Fig.  50. 


Pus-corpuscles;  those  at  tlie  lower  part  of  the  field  exhibit  the 
action  of  acetic  acid  on  the  corpuscles. 


action  of  acetic  acid  develops  the  filaments  of  mucin.  Sometimes, 
also,  there  are  thin  flakes  of  cylindrical  bodies,  unlike  any  appear- 
ance exhibited  by  pus.  Yet,  when  the  urine  is  strongly  ammo- 
niacal,  even  the  microscope  does  not  furnish  a  certain  test;  for  the 
salts  of  ammonia  obliterate  the  distinctive  pus-globules  and  con- 
vert pus  into  a  slimy  mass,  in  which  nothing  but  the  nuclei  may 
be  distinguishable. 

The  occurrence  of  pus  in  the  urine  is  a  sign  of  suppuration 
somewhere  in  the  genito-urinary  system,  or  a  proof  that  an  ab- 
scess has  opened  into  it.  But  as  to  the  exact  seat  of  the  forma- 
tion of  the  pus,  its  existence  in  the  urine  affords  no  clue.  To 
some  extent,  however,  we  can  judge  of  this  by  the  microscopical 
appearance  of  the  corpuscles.  When  these  are  round  and  well 
developed,  with  their  characteristic  nuclei  readily  brought  out  by 
acetic  acid,  they  generally  have  their  origin  in  a  catarrhal  inflam- 
mation of  the  mucous  membrane,  especially  of  the  bladder.     On 


708  MEDICAL    DIAGNOSIS. 

the  other  hand,  as  Vogol  points  out,  pus-corpuscles  of  irregular 
contour,  exhibiting  irregular  nuclei  when  treated  with  acetic  acid, 
or  an-  ill-defined  granular  mass,  consisting  of  irregularly-shaped 
pns-c'orpnscles  and  partly-destroyed  cells,  indicate  the  probable 
existence  of  deep-seated  suppuration,  ulceration,  or  tubercular  dis- 
ease. The  sudden  appearance  in  the  urine  of  large  quantities  of' 
pus  ]M)ints  to  the  bursting  of  an  abscess ;  an  abundant  deposit 
of  pus  in  acid  urine  is  chiefly  noticed  in  pyelitis  and  in  chronic 
atonic  cystitis. 

Fat. — Fatty  matter  may  occur  in  the  urine  in  various  forms 
and  in  diifcrcnt  conditions.  It  may  be  found  in  the  shape  of 
globules,  when  oil  or  milk  has  been  added  to  the  urine  for  pur- 
poses of  deception,  or  when  the  former  article  has  been  swallowed 
for  some  time  in  considerable  quantities,  as  for  instance  during 
the  administration  of  cod-liver  oil.  Fat  is  also  encountered  in 
globules  of  varying  size,  either  free,  in  cells,  or  in  tube-casts,  as 
in  fatty  degeneration  of  the  kidneys.  Fat,  too,  may  be  found  in 
the  urine  in  phosphorus-poisoning  and  after  fractures. 

The  tests  for  fat  are  its  solubility  in  ether,  and  its  microscopical 
characters.  Lee  and  Atlee  have  pointed  out  *  an  illusory  detec- 
tion of  fat.  They  found,  in  testing  a  specimen  of  urine,  that  the 
ether  rose  to  the  top  so  charged  with  matter  as  to  resemble  a  half- 
liquid  pomade.  Separated  by  a  pipette  and  spontaneously  evapo- 
rated, it  left  a  dirty-whitish  greasy  mass.  A  careful  examination 
of  this  residue  showed  that,  instead  of  cousisting  of  fatty  acids,  it 
contained  nothing  but  the  normal  constituents  of  the  urine,  for  it 
was  soluble  in  ^^'ater,  reappearing  as  normal  urine.  It  Avas  then 
ascertained  that  almost  any  urine  will  form  an  emulsion  when 
violently  agitated  with  ether,  especially  if  the  ether  contain  a 
small  amount  of  alcohol.  When,  therefore,  ether  appears  to  dis- 
solve out  fatty  matter  from  urine,  the  ethereal  solution  should 
be  separated,  and  allowed  to  evaporate  spontaneously,  and  if  the 
residue  be  soluble  in  water  it  cannot  be  held  to  contain  fat. 

There  is  no  certainty  of  the  presence  of  fat  unless  the  sediment 
be  examined  chemically  and  microscopically.  The  opalescence 
of  urine  caused  by  a  sediment  of  urates  has  been  mistaken  for 
that  from  oily  matter,  and  so  also  has  been  the  pellicle  which 

*  Amer.  Journ.  Med.  Sci.,  April,  1869,  p.  357. 


THE    URINE,  AND    DISEASES    OF   THE    URINARY    ORGANS.       709 

often  forms  on  urine,  and  which  consists  not  of  fat,  l)ut  of  vibri- 
ones,  fungi,  and  crystals  of  the  triple  phosphates.  The  ''  kyestein" 
pellicle  observed  in  the  pregnant  state  is  of  similar  kind,  though 
some  oily  matter  may  enter  into  its  composition. 

In  some  cases  fat  is  met  with  in  a  molecular  state,  imparting  to 
the  urine  a  milky  appearance,  to  which  the  name  chylous  urine 
has  been  given,  and  which  disappears  on  its  admixture  with  ether. 
The  condition  does  not  depend  upon  any  permanent  morbid  change 
in  the  kidney ;  the  chylous  character  of  the  urine  is  intimately 
connected  with  the  absorption  of  chyle,  but  precisely  how  the 
urine  acquires  that  character  is  uncertain.  It  may  be  absent  in 
the  day  urine  and  very  marked  in  the  night  urine.  The  affection 
may  continue  for  years  without  impairment  of  the  general  health, 
being  always  perceptibly  increased  by  exercise.*  In  the  tropics 
chylous  urine  has  been  often  found  in  connection  with  parasites, 
with  the  Filaria  sanguinis  hominis,  and  this  is  its  most  usual 
cause.  The  Filaria  sanguinis  has  been  detected  in  the  blood  of 
persons  in  the  southern  part  of  this  country  by  Guiteras. 

A  urine  which  spontaneously  coagulates  soon  after  being  voided, 
owing  to  fibi-in,  a  fibrinuria,  is  very  uncommon  except  in  the  Isle 
of  France  and  in  Brazil.  A  thick  urine  may  be  due  to  pus  dis- 
solved in  alkalies,  as  in  certain  bladder  affections.  But  the  thick 
matter  is  at  once  greatly  thinned  by  water,  and  on  the  addition  of 
acetic  acid  a  white  precipitate  of  alkaline  albuminate  falls. f 

Sediments.— In  connection  with  the  ingredients  of  the  urine, 
the  nature  of  the  urinary  sediments  has  been  discussed,  and  it  has 
been  insisted  that  they  cannot  be  accurately  determined  save  by 
a  microscopical  examination.  I  shall  here  only  group  together 
their  general  characteristics  : 

1.  A  light  and  flocculent  cloudy  deposit  is  commonly  mucus, 
entangling  epithelial  cells,  bacteria,  or  spermatozoa. 

2.  A  dense,  abundant,  white  deposit  is  generally  composed  of 
urates  or  phosphates ;  but  it  may  be  pus  or  extraneous  matter. 

3.  A  yellow  or  pink  deposit  is  almost  always  due  to  urates. 

*  See  cases  of  the  disorder  in  the  papers  of  Bence  Jones,  Medico-Chirurgical 
Transactions,  1850-53  ;  of  Gubler,  Gazette  Medicale  de  Paris,  1858 :  and  of 
Isaacs,  Transactions  of  New  York  Academy  of  Medicine,  vol.  ii. ;  also  Beale, 
Urinary  and  Kenal  Derangements,  1885,  and  Koberts  on  Urinary  Diseases. 

I  Hofmann  and  Ultzmann,  op.  cit. 


710 


MEDICAL   DIAGNOSIS. 


4.  A  oramilar  or  crystalline  deposit,  of  reddish  or  dark-brown 
color  and  small  in  quantity,  is  uric  acid. 

5.  A  dark,  sooty  or  dingy-red  deposit  is  blood. 

.  The  following-  table  may  serve  a  useful  purpose,  in  showing 
how  both  the  sediments  and  the  soluble  urinary  ingredients  are 
aifected  by  the  reagents  commonly  employed  : 


Specific  Gray 
ITY 


Hi  oh. 


Low 


Table  exhibiting  the  Action  of  the  Main  Reagents   employed  in 

THE  Examination  of  the  Urine. 

Urine     high-col-  f  Increase  of  urea, 

ored I      uric  acid,  etc. 

Urine  pale Diabetes. 

Urine     high-col-   f  Certain  forms  of 

•ed  or  normal  I     Bright's  disease. 

pale Excess  of  water. 

Soluble   in  nitric   r 

.-,  i   Phosphates, 

acid \  ^ 


i  Urine 
ored 
Urine 


r 


Heat. 


Throws  down  de- 


Nitric  Acid. 


"-      acid 

Dissolves  deposit  <   Urates. 

Does  not  dissolve   f  Uric  acid, 
deposit I  Phosphates. 

Quickly 

Precipitates. 

More  gradually. 

f  Earthy  phos- 

Iphates. 
Alkaline  phos- 
phates, 
l^  Oxalates. 

Produces  play  of  |  Bile-pigment, 
color 1 

'  Precipitates. 
Transforms.. 


c    f  ben 
..  \  Sen 


um-aiobulin. 


f  Albumen. 
\  Propeptones. 

Uric  acid. 

Crystals   of   urea 
nitrate. 


Hydrochloric 
^ciD 1   Detects,   by    vio- 
let   change  of 
[      color 

r 


-j   Uric  acid. 

f  Urates   into   uric 

\      acid. 


Uroxanthin 
indican. 


Brown. 


Urohfematin. 


Sulphuric 
Acid 


Changes  color  of  J 
urine i 


Crimson  or  violet   /■ 

(if  sugar  have  <   Biliary  acids. 
I       been  added)....    ^ 
I   Violet <   Indican. 


THE    UEINE^  AND    DISEASES    OF   THE    UHINAEY    ORCIANS.       711 


Table  exhibiting  the  Action  of  the  Main  Reagents  employed  in 
TUB  Examination  oe  the  Ukine. — Continued. 
Precipitates      de-   f 
posit  (not  solu-  J 
ble  in  excess  of    |   J^^^cus. 
Acetic  Acid....  [       the  acid) [ 

■v,t\  t.Vi      r 

Albumen         and 
propeptone. 

j   The  albuminates, 
also       peptone 


Precipitates  with 
potassium  fer- 
rocyanide 


Picric  Acid <j  Precipitates -| 


and  propep- 
tone, which  are 
dissolved  by 
heat. 

Eed  deposit — 
blood. 

Slowly  developed 
haze — mucin. 


f  On  boiling,  turns   f 

A   Sugar. 


Solution 


Deposits  of  urates. 


urine  brown. 

,olutio.        ok    ,   ^.^^^^^^^ .  Uric  acid. 

Caustic  Soda.  ^  I  Deposits  of 

Forms  gelatinous   r 

raass \   "^^- 

Precipitates |  ^^^'^^^^   P^"^" 

(.       r»hates. 


Liquor  Ammo- 
NliE 


Solution  of 
Chloride  of 
Barium 


[  Dissolves \   Cystine. 


r 


Precipitates. 


j  Phosphates. 
I  Sulphates. 


Nitrate  of 
Silver ^   Precipitates. 


Alkaline 
phates. 


phos- 


Alkaline  Cop- 
per Solu- 
tion  


f  Precipitates  with 
I  heat  yellowish- 
\       red  deposit 

I   Turns  violet 


Deposit  soluble 
in  free  acid. 

Deposit  insoluble 
in  acids. 

Yellow     deposit, 
soluble    in    ni- 
tric   acid     and 
ammonia. 
-    White      deposit,   [" 
insoluble        in   | 

nitric  acid,  but  -{   Sodium  chloride, 
soluble  in  am- 
monia. 

Sugar. 

In  cold I  Peptone. 

I  Propeptone. 
With  heat Serum-albumen. 


712  MEDICAL    DIAGNOSIS. 

Table  exhibiting  the  Action  of  the  Main  Eeagents  employed  in 
THE  Examination  of  the  Urine. — Continued. 

Potassium  f  Precipitates      on  r 

Pekrocyan-  J       addition         of  \   I'ropcptone. 
IDE acetic  acid [  Serum-ulbumen. 


Precipitates /  Albumen. 


Ether i   Dissolves 


Hippuric  acid, 
soluble  in  alco- 
hol. 

Fat. 

l  Does  not  dissolve  \  Uric  acid. 

UEINAEY   ORGANS. 
Diseases  of  the  Kidney  of  wMcli  Pain  is  a  Prominent  Symptom. 

This  group  embraces  acute  inflammation  of  the  kidney,  and 
those  painful  affections  classed  under  the  term  nephralgia. 

Nephritis. — Acute  inflammation  of  the  kidney  is  chiefly  ob- 
served in  old  persons  and  in  damp  climates.  It  may  be  occa- 
sioned by  an  attack  of  acute  rheumatism,  by  direct  violence  to 
the  organ,  or  by  the  irritation  of  a  calculus ;  but  probably  its 
most  frequent  cause  is  exposure. 

It  begins  with  a  chill,  soon  followed  by  fever.  The  pulse  is 
small  and  hard,  the  skin  is  frequently  dry.  There  are  nausea 
and  vomiting,  and  at  times  diarrhoea  with  tenesmus.  The  urine 
is  voided  drop  by  drop ;  it  is  red,  and  may  contain  blood.  The 
patient  complains  of  pain  in  the  renal  region,  sometimes  dull,  at 
other  times  sharp  and  lancinating,  and  augmented  by  pressure  and 
by  moving.  The  pain  is  not  limited  to  the  kidney,  but  radiates 
to  the  diaphragm  and  to  the  bladder.  With  it  are  often  asso- 
ciated numbness  of  the  thigli  of  the  affected  side  and  retraction 
of  the  testicle.  The  disease  may  occur  in  both  kidneys ;  yet  it 
rarely  affects  more  than  one.  It  lasts  from  one  to  three  weeks, 
and  generally  terminates  in  resolution.  But  it  may  lead  to  sup- 
puration and  disorganization  of  the  organ. 

The  disorder  is  recognized  by  the  pain,  the  fever,  the  retraction 
of  the  testicle,  and  the  appearance  of  the  urine.  It  differs  from 
an  attack  of  colic  by  the  signs  of  disturbance  of  the  urinary 


THE   UmXE,  AND   DISEASES   OF   THE   URINARY   ORGANS.      713 

organs,  by  the  seat  of  the  pain,  and  by  the  fever ;  from  rheumatic 
pains  in  the  back,  by  the  former  of  these  symptoms.  Then,  in 
lumbago  we  rarely  find  much  febrile  excitement,  nor  are  there 
nausea  and  vomiting,  or  numbness  along  the  course  of  the  ante- 
rior crural  nerve ;  but,  on  the  other  hand,  the  pain  is  much  more 
influenced  by  movements,  especially  by  stooping  and  such  other 
motions  as  call  the  muscles  of  the  back  into  play.  Congestion 
of  the  kidneys  is  distinguished  from  inflammation  by  its  aflecting 
both  sides,  by  the  absence  of  protracted  or  severe  pain,  and  by 
the  comparatively  slight  derangement  of  the  urinary  functions. 
Further,  the  congestion  is  not  idiopathic,  and  we  can  generally 
trace  it  to  the  swallowing  of  some  irritating  substance,  or  to  the 
poison  of  a  febrile  malady,  such  as  smallpox  or  typhus.  From 
the  passage  of  a  renal  calculus  acute  nephritis  differs  by  the  steady, 
less  paroxysmal  and  less  violent  ]3ain,  which  does  not,  as  in  renal 
colic,  begin  suddenly  and  end  suddenly ;  by  the  fever,  by  the 
bloody  urine,  and  by  the  absence  of  a  history  of  previous  attacks. 

Nephralgia. — Severe  pain  in  the  kidney,  unconnected  with 
inflammation  of  the  organ,  is  ordinarily  caused  by  the  passage  of 
a  calculus.  With  reference  to  the  diagnosis,'  the  complaint  may 
be  confounded  with  the  same  maladies  as  nephritis,  and  the  differ- 
ences are  identical  as  between  nephritis  and  the  ailments  resem- 
bling it,  except,  of  course,  that  we  must  leave  out  of  consideration 
any  indications  afforded  by  febrile  signs,  although  passing  eleva- 
tions of  temperature  may  happen.  Nephralgia  exhibits  a  great 
similarity  to  colic ;  but  this  has  already  been  discussed ;  and  in 
particular  cases  we  are  often  much  aided  by  the  knowledge  that 
in  "  renal  colic"  the  patient  has  on  a  former  occasion  passed  renal 
concretions. 

The  amount  of  pain  varies  according  to  the  magnitude  of  the 
stone  and  its  character.  As  a  rule,  calculi  composed  of  oxalate  of 
lime  give  rise  to  most  pain.  We  may  distinguish  them  by  their 
roughness  and  irregularity,  and  their  brown  or  dark-gray  color ; 
those  of  uric  acid  and  urates  are  reddish  and  much  softer,  and  not 
jagged,  and,  unlike  calculi  consisting  of  the  salts  of  lime,  are  com- 
bustible on  platinum  foil,  leaving  a  mere  trace  of  residue,  while 
the  oxalate  of  lime  calculus  leaves  considerable  residue,  and  is 
soluble  in  mineral  acids  without  effervescence.  Calculi  of  the 
mixed  phosphates  are  white,  very  brittle,  soluble  in  acids,  insoluble 


714  MEDICAL   DIAGNOSIS. 

in  alkalies,  and  fuse  in  the  blow-pipe  Hame.  The  mixed  phos- 
phates rarely  form  a  stone  entirely,  being  often  only  an  incrusta- 
tion around  a  blood-coagulum  or  a  foreign  body,  or  having  a 
kernel  of  lu'ie  aeid.  Indeed,  the  majority  of  phosphatie  stones 
have  uric  aeid  centres,  while  calculi  of  uric  acid  or  its  salts  possess, 
as  a  rule,  the  same  composition  throughout ;  calculi  of  oxalates 
have  oflen  a  nucleus  of  uric  acid  and  a  crust  of  phosphates. 
Xanthine  and  cystine  are  the  rarer  constituents  of  stones.  The 
former,  like  uric  acid  and  the  ammonium  and  sodium  urates,  is 
consumed  by  heat,  and  burns  without  visible  flame,  but  the  mu- 
rexide  test  exhibits  an  orange-yellow  color ;  cystine  burns  with  a 
bluish-white  flame,  emitting  an  odor  like  that  of  burning  fat,  and 
the  powder  is  soluble  in  dilute  ammonia.  The  crystallization  of 
the  ingredients  of  the  urine  forming  a  calculus  is  very  apt  to  take 
place  around  particles  of  mucus. 

As  already  stated,  we  have  in  the  severity  of  the  pain  a  sign 
indicative  of  the  nature  of  the  case.  Still,  there  are  states  in  which 
'paroxysms  of  pain  referred  to  the  neighborhood  of  the  kidney 
are  attributable  to  other  causes  than  the  passage  of  a  calculus. 
Leaving  out  of  consideration  that  doubtful  disease,  pure  neuralgia 
of  the  kidney,  we  find  a  few  affections — very  rare,  it  is  true — 
which  closely  simulate  the  passage  of  a  renal  calculus. 

The  first  of  these  is  the  pain  occasioned  by  an  inflamed  and 
ulcerated  ureter.  Todd  relates  a  case  of  the  kind.*  The  patient 
had  severe  attacks  of  lancinating  pain,  referred  to  the  right  loin, 
lasting  for  weeks,  and  accompanied  by  constant  and  intractable 
vomiting.  The  urine  contained  pus  in  varying  quantity,  but 
neither  blood  nor  calculous  matter  could  be  detected.  At  one 
time  he  continued  free  from  any  paroxysm  for  four  years.  After 
death  the  most  careful  search  Avas  made  for  a  calculus,  but  none 
could  be  discovered.  The  ureter  of  the  right  side  was  thickened 
throughout  the  greater  part  of  its  course,  and  deposits  of  lymph 
adhered  to  its  mucous  membrane.  A  somewhat  similar  train  of 
phenomena  may  occur  from  an  irritation  or  inflammation  of  the 
ureter  caused  by  the  poison  of  rheumatism  or  gout,  although  the 
paroxysms  of  pain  are  apt  to  be  neither  so  severe  nor  of  so  long 
duration. 

*  Clinical  Lectures,  Lecture  II.,  ou  Diseases  of  the  Urinary  Organs. 


THE   URINE,  AND   DISEASES   OF   THE   URINARY   ORGANS.       715 

Another  morbid  condition  closely  resembling  the  passage  of  a 
renal  calculns  may  result  from  malarial  poison.  How  close  this 
resemblance  may  be,  the  following  case  will  show : 

A  soldier,  twenty-four  years  of  age,  of  fair  complexion,  and 
evidently  of  strong  constitution,  was  seized  rather  suddenly  with 
pain  over  the  left  kidney.  The  loin  was  sensitive  to  the  touch, 
and  appeared  somewhat  red  and  swollen.  The  skin  was  hot;  the 
pulse  100.  The  urine  was  not  found  to  be  abnormal,  though  con- 
taining a  reddish  coloring-matter.  The  pain  continued  for  several 
days,  becoming  more  severe,  notwithstanding  that  by  direction  of 
Dr.  Hilborne  West,  under  whose  charge  the  man  was,  and  with 
whom  I  saw  him,  six  ounces  of  blood  were  drawn  from  near  the 
affected  part.  On  the  fourth  day  of  the  disorder  the  patient 
was  assailed  with  excruciating  pain  along  the  course  of  the  ureter, 
attended  with  the  voiding,  at  short  intervals,  of  a  high-colored 
urine.  The  attack  lasted  from  six  o'clock  in  the  evening  until 
five  o'clock  the  next  morning,  leaving  the  patient  much  exhausted ; 
the  only  relief  throughout  its  duration  being  obtained  from  the 
inhalation  of  chloroform.  At  six  o'clock  that  evening  another 
seizure,  of  equal  violence,  set  in;  and,  after  the  lapse  of  twenty- 
four  hours,  again  another.  Seeing  the  recurrence  of  the  parox- 
ysms at  about  the  same  time  of  each  day,  and  learning  from  the 
patient  that  a  few  months  before  he  had  had  a  remittent  fever, 
which  had  left  behind  an  irregular  intermittent,  we  resolved  upon 
the  administration  of  large  doses  of  sulphate  of  quinine  in  the 
interval  between  the  paroxysms.  The  seizure  did  not  take  place 
that  night ;  but,  the  remedy  being  a  day  or  two  afterward  sus- 
pended, the  fourth  night  was  again  a  night  of  anguish.  The 
antiperiodic  was  resumed,  and  continued,  in  lessened  doses,  for 
three  weeks.  The  patient  remained  under  observation  for  about 
six  weeks  after  the  last  attack,  gradually  recovering  his  health  and 
spirits.  When  he  was  lost  sight  of,  there  was  still  a  dull  pain  in 
the  left  lumbar  region,  with  inability  to  stand  erect;  but  no  return 
of  the  excruciating  intermittent  pains. 

In  a  case  of  this  kind  it  is  evident  that  nothing  but  a  knowl- 
edge of  the  history  of  the  patient,  and  the  noting  of  the  regularly- 
recurring  onsets  of  the  pain,  could  have  led  to  a  correct  apprecia- 
tion of  its  cause.  We  sometimes  meet  with  a  so-called  neuralgia 
of  the  bladder,  of  similar  origin,  and  having  much  the  same 


716  MEDICAL   DIAGNOSIS. 

symptoms,  except  tliat  the  distressino;  pain  is  referred  to  the 
bhidder.  As  in  tlie  case  just  detaikd,  the  attacks  oecnr  at  night. 
These  remarks  are  all  based  on  tlie  assumption  that  the  renal 
pain  is  very  severe  and  paroxysmal  in  its  character.  Let  us  now 
brieriy  inquire  into  the  signihcance  of  a  steady  and  less  acute  pain, 
premising  that  we  have  excluded  from  consideration  abdominal 
aneurism,  affections  of  the  muscles  of  the  back,  of  the  spine, 
and  of  the  tissues  surrounding  tlie  kidney,  in  which  diagnosis,  of 
course,  we  are  materially  assisted  by  an  examination  of  the  urine. 
An  ingenious  application  of  the  effect  of  cocaine  has  been  made 
in  the  study  of  pain.  If  a  urethral  injection  of  a  twenty-per- 
cent, solution  of  cocaine  immediately  relieve  pain  in  the  kidneys, 
E.  H.  Fenwick  points  out,*  we  may  recognize  a  transient  and 
unimportant  cause  for  it,  such  as  congestion,  uric-acid  urine, 
pressure  of  the  colon.  If  the  renal  pain  be  uninfluenced,  a  stone 
or  renal  cancer  may  be  suspected. 

AVe  meet  with  j^o'sisknt  jja/n  referable  to  the  kidney  itself,  in 
inflammation  of  the  organ,  especially  in  that  variety  of  inflamma- 
tion affecting  the  infundibula  and  pelvis,  termed  pyelitis.  We 
also  encounter  it  in  malignant  disease  of  the  kidney ;  sometimes, 
although  it  is  not  then  of  long  duration,  from  the  irritation  of 
concentrated  and  highly-acid  urine ;  much  more  generally  from 
the  presence  of  a  stone  lodged  in  the  kidney.  The  pain  in  the 
latter  complaint  often  extends  along  the  course  of  the  ureter  to 
the  testicle,  M'hich  is  retracted  and  swollen.  Not  unfrequently 
there  is  also  tenderness  on  pressure  over  the  affected  kidney, 
and  the  pain  is  greatly  increased  by  active  exercise;  and  it  is  not 
uncommon  to  find,  associated  with  these  exacerbations  of  pain, 
nausea  and  vomiting,  and  the  appearance  of  blood  in  the  urine. 

There  is  yet  another  point  in  the  diagnosis  of  the  passage  of 
calculi  Avhich  we  must  not  overlook, — namely,  that  the  pain  may 
be  referred  to  other  parts  than  to  the  region  of  the  kidney  and  the 
course  of  the  ureter.  It  may  be  felt  near  or  at  the  sacrum,  and 
not  merely  on  one  side  ;  it  may  extend  to  the  bladder  and  become 
associated  with  a  painful  spasm  of  this  vis(3us  and  with  the  void- 
ing of  urine  drop  by  drop ;  or  to  the  testicle,  which  becomes  sen- 
sitive and  swells ;  or  to  the  thigh,  which  feels  numb ;  or  it  may 

*  Lancet,  May  5,  1888. 


THE^URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       717 

be  referred  to  the  right  hypochondrium  and  extend  do^vnvvard, 
but  not  be  perceived  in  the  loin.  Under  the  latter  circumstances 
there  may  be,  with  pain  of  great  intensity,  coexisting  distention 
of  the  colon,  vomiting,  and  constipated  bowels,  and  tlic  symptoms 
so  closely  resemble  those  of  the  passage  of  a  biliary  calculus  that 
only  the  detection  of  blood  in  the  urine  prevents  error.*  Again, 
as  happened  in  two  cases  which  came  under  my  notice,  the  pain 
may  be  referred  to  the  left  hypochondrium  or  along  the  course  of 
the  colon,  may  be  associated  with  soreness  to  the  touch  and  with 
digestive  disorders,  and  may  closely  simulate  an  organic  lesion  of 
the  stomach  or  intestine.  Nothing  but  careful  and  repeated  ex- 
aminations of  the  urine,  and  observing  the  irregular  and  whimsical 
course  the  supposed  intestinal  malady  pursues,  will  enable  us  to 
arrive  at  a  knowledge  of  the  truth. 

Nor  must  we  be  unmindful  that  a  calculus  may  be  months  in 
passing,  and  that  as  it  changes  its  position  the  seat  of  the  pain 
changes.  I  had  a  case  of  the  kind  under  my  charge  in  a  lady 
about  fifty  years  of  age.  She  suffered  for  weeks  at  a  time  from 
excruciating  pains,  beginning  in  the  left  kidney,  then  felt  some- 
what below  it,  and  finally  localized  in  the  neighborhood  of  the 
left  ovary.  She  was  occasionally  free  from  pain  for  five  or  six 
days.  But  it  was  only  after  fully  nine  months  of  recurring 
suffering  that  the  passage  of  a  calculus  the  size  of  a  plum-stone, 
followed  by  a  discharge  of  large  amounts  of  a  gritty  substance 
and  a  soapy-looking  urine,  removed  her  distress.  The  stone 
consisted  of  urates. 

The  symptoms  of  renal  calculus  may,  after  having  existed  for 
a  longer  or  shorter  time,  entirely  cease,  owing  either  to  the  calcu- 
lus becoming  encysted  and  thus  remaining  innocuous,  or  to  its 
obstructing  the  ureter,  causing  retention  of  the  urine,  and,  by 
pressure,  producing  gradual  atrophy  of  the  cortical  and  tubular 
structures,  the  kidney  being  finally  converted  into  a  mere  bag. 

In  concluding  the  subject,  it  will  be  useful  to  group  together 
the  symptoms  by  which  we  may  infer  the  existence  of  a  calculus 
in  the  kidney.  They  are  :  frequent  micturition,  often  attended 
with  pain  at  the  end  of  the  penis ;  pain  in  the  loin,  with  or  with- 
out accompanying  soreness,  occasionally  passing  suddenly  into  a 

*  Case  of  Owen  Eees,  Guj-'s  Hospital  Eeports,  3d  Series,  vol.  x. 


718  MEDICAL   DIAGNOSIS. 

violent  paroxysm,  with  a  tendency  to  shoot  aking-  the  course  of 
the  ureter  to  the  testicle  and  the  hip  of  the  aching  side;  and  in 
some  cases  the  discharge  of  pus  due  to  coincident  pyelitis.  These 
symptoms  become  positive  evidence  if  the  blood-extractives  be 
present  in  the  patient's  urine,  or  if  this,  when  examined  micro- 
scopically, be  found  to  contain  blood-corpuscles;  or  ii"  we  know 
that  attacks  of  luomaturia  have  previously  hapjicncd,  and  that 
gravel  or  small  urinary  concretions  have  at  any  time  been  dis- 
charged. The  presence,  too,  in  the  urine  of  microscopic  calculi, 
as  Beale  shoMs,  points  to  the  existence  of  larger  concretions  in 
the  pelvis  or  in  the  structure  of  the  kidney.  But  all  these  indi- 
cations are  far  from  being  always  present.  The  renal  stones 
may  be  so  large  that  they  cannot  leave  the  kidney  ;  we  may  have 
nothing  but  the  symptoms  of  a  pyelitis,  which  Ave  suspect  to  be 
calculous,  and  e^-en  these  symptoms  may  be  wanting.  To  deter- 
mine whether  both  kidneys  are  implicated  in  the  calculous  disease, 
we  must  examine  the  urine  during  the  passage  of  a  renal  cal- 
culus. If  the  urine  become  perfectly  healthy,  when  previously 
it  has  been  abnormal,  we  conclude  that  it  comes  from  a  healthy 
kidney,  and  that  the  secretion  from  the  diseased  one  is  tempo- 
rarily blocked  up. 

Diseases  marked  by  an  Albuminous  Condition  of  the  Urine, 
associated  with  more  or  less  Dropsy. 

The  chief  of  these  diseases  is  Bright's  disease.  It  is  the  tendency 
of  the  present  day  to  prove  that  the  disease  wdiich  bears  Bright's 
name  consists  of  a  group  of  maladies  having  the  common  feature 
of  a  more  or  less  albuminous  state  of  the  urine.  But,  though  I 
believe  this  view  to  be  the  correct  one,  I  shall,  in  this  sketch, 
prefer  to  consider  the  disorder  in  the  main  as  it  is  seen  separated 
by  broadly-drawn  lines  into  an  acute  and  a  chronic  form,  incorpo- 
rating such  recently-acquired  facts  as  have  a  readily-discerned  and 
special  diagnostic  bearing. 

Acute  Bright's  Disease. — In  this  form  of  the  affection  the 
symptoms  are  of  an  acute  character.  Especially  so  is  the  dropsy, 
which  is  quickly  developed  and  soon  becomes  the  most  marked 
token  of  the  malady.  The  history  of  a  large  number  of  cases  is 
as  follows.     After  exposure  to  wet  or  cold,  a  fever  sets  in,  accom- 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       719 

panied  by  nausea,  and  by  a  dull  pain  in  the  region  of  both  kid- 
neys, extending  along  the  ureters.  The  eyelids  and  face  become 
puffy  and  swollen,  and  soon  a  general  oedematous  condition  of  the 
skin  is  observable,  showing  itself  very  plainly  in  the  extremities, 
scrotum,  and  abdominal  parietes.  Subsequently  dropsical  effusions 
often  take  place  into  the  interior  cavities. 

The  same  symptoms  are  noticed  in  the  acute  Bright's  disease,  or 
the  acute  parenchymatous  nephritis,  which  so  constantly  attends 
scarlatina,  except  that,  following  as  it  does  an  exhaustive  disease, 
there  are  from  the  onset  much  greater  pallor  and  general  debility. 
Acute  parenchymatous  nephritis  is  also  met  with,  though  far  less 
frequently,  in  other  infectious  diseases,  as  in  smallpox.  It  may 
follow  a  lightning-stroke.* 

The  urine  in  the  acute  malady  is  of  high  siDCcific  gravity,  and 
dingy  from  its  admixture  with  blood.  There  is  a  frequent  desire 
to  void  it,  although  the  whole  quantity  passed  is  rather  below  the 
natural  average.  The  urine  contains  a  large  amount  of  albumen ; 
a  microscopical  examination  brings  to  light  casts,  lined  here  and 
there  with  blood-corpuscles.  As  the  malady  progresses,  these 
"blood-casts"  disappear,  and  we  find  the  coagulable  material 
which  has  been  effused  into  the  tubes  coated  with  epithelium, 
which  may  be  normal  or  slightly  fatty,  and  with  free  nuclei ;  or 
we  observe  it  to  be  slightly  granular,  or  quite  homogeneous ;  or 
we  may  discern  pus-globules  taking  the  place  of  the  epithelial 
cells.  Furthermore,  crystals  of  uric  acid,  of  urates,  even  of  oxa- 
lates, and  a  considerable  amount  of  renal  epithelium,  are  objects 
often  seen  in  the  sediment.  We  may  also  find  long  cylindrical, 
ribbon-like  mucous  casts,  which  were  first  detected  in  the  urine 
of  scarlet  fever,  but  are  in  no  way  characteristic  of  renal  disease, 
since  they  are  also  encountered  in  cystitis  and  in  retention  of 
urine.  The  normal  constituents  of  the  urine  are  considerably 
changed.  The  chlorides  may  have  disappeared  altogether ;  the 
phosphates  are  diminished  ;  the  uric  acid  and  the  pigments  are 
increased.  The  amount  of  urea  fluctuates  much :  it  may  be  either 
augmented  or  diminished. 

There  is  moderate  fever,  with  a  temperature  of  about  101°; 
the  pulse,  however,  may  be  quick,  tense,  and  full.     The  skin  is 

*  Medical  and  Surgical  Eeporter,  July  23,  1887. 


720 


MEDICAL   DIAGNOSIS. 


generally  harsh  and  drv  ;  nausea  and  vomiting-  arc  of  common 
occurrence. 

The  -urgent  symptoms  last  ordinarily  for  several  weeks.  When 
recovery  is  about  to  take  place,  they  abate ;  the  temperature  be- 
comes normal,  the  skin  moist,  and  hand  in  hand  with  a  diminution 
of  the  dropsy  the  quantity  of  the  urine  largely  increases  and  the 

Fig.  51. 


Epithelial  casts  and  einthelial  colls  from  the  kidneys  found  in  a  case  of  acute 
Bright's  disease  {acute  destjuumulive  uexiliritis);  magnified  about  4G0  diameters. 

albumen  gradually  disappears.  But  this,  although  fortunately 
the  common,  is  not  the  invariable  issue.  The  disease  may  grad- 
ually lapse  into  a  chronic  form.  Or  a  certain  amount  of  albumen 
may  remain  in  the  urine;  and  after  exposure  this  increases,  and 
the  dropsy  and  most  of  the  acute  symptoms  return. 

There  is  a  form  of  acute  Bright's  disease  due  to  a  bacillus. 
Letzerich*  describes  it  as  "nephritis  bacillosa  interstitialis  pri- 
maria."  It  occurs  in  children,  runs  its  course  in  from  two  to 
six  weeks  Avith  a  moderate  fever,  and  generally  ends  in  recovery. 
The  urine  contains  red  blood-corpuscles,  a  few  leucocytes,  only 
small  amounts  of  albumen,  but  great  numbers  of  bacilli,  shorter 
and  thicker  than  the  tubercle-bacilli,  and  easily  stained  with 
methyl-violet. 

Whatever  the  attending  circumstances,  the  risk  to  life,  when 
an  attack  of  acute  Bright's  disease  has  been  at  all  prolonged,  is 


*  Neurol.  Centralbl.,  1887,  quoted  in  Sajous's  Annual,  1888,  p.  483. 


THE    URINE,  AND    DISExVSES    OF    THE    URINARY   ORGANS.       721 

greatly  increased  by  the  supervention  of  local  inflammations, — 
as  of  the  pleura,  lungs,  peritoneum,  or  pericardium ;  or  by  the 
sudden  effusion  of  fluid  into  the  pulmonary  structure ;  or  by  the 
retention  of  urea  in  the  blood  and  consequent  urgemic  intoxication. 

The  recognition  of  the  disease  is  readily  effected.  The  puffy, 
pale  face ;  the  general  droj)sy ;  the  albumen  in  the  urine,  associated 
with  tube-casts, — form  a  combination  of  signs  so  remarkable  that 
it  is  difficult  to  mistake  their  meaning.  Many  of  the  same  phe- 
nomena are  encountered  in  the  chronic  form  of  the  malady  :  what 
is  therefore  about  to  be  said  of  the  differential  diagnosis  of  the 
acute  complaint  may  be  in  the  main  applied  with  almost  equal 
correctness  to  the  chronic  ailment. 

The  chief  disorders  with  which  acute  Bright's  disease  is  apt  to 
be  confounded  are : 

Acute  Nephritis  ; 
.   Suppurative  Nephritis  ; 

HEMATURIA    AND    PuRULENT   UrINE  ; 

Simple  Albuminuria  ; 

Pulmonary  CEdema  ; 

Pleurisy  and  Pericarditis  ; 

Dropsy  ; 

Coma  ;  Convulsions. 

Acute  Nephritis. — This  differs  from  acute  Bright's  disease  by 
its  affecting  generally  only  one  kidney,  by  the  much  greater  pain 
and  tenderness  in  the  lumbar  region,  by  the  retraction  of  the 
testicle,  and  by  the  higher  degree  of  febrile  excitement.  Then, 
too,  the  deeply-colored  urine  which  is  voided  contains  little  or 
no  albumen. 

Suppurative  Nephritis. — In  rare  cases  the  suppurative  process 
may  coexist  with  Bright's  disease.  But,  on  the  whole,  the  two 
disorders  are  distinct,  and  may  be  readily  discriminated.  Suppu- 
rative nephritis  occurs  from  external  violence,  from  exposure  to 
cold  and  wet,  from  a  morbid  condition  of  the  blood,  as  in  pysemia, 
from  metastasis  through  embolism,  or  from  the  impaction  of  a 
renal  calculus,  and  may  lead,  like  Bright's  disease,  to  uraemic 
symptoms.  But  it  usually  attacks  only  one  kidney,  occasions 
much  local  pain,  is  frequently  attended  with  a  fever  more  or  less 
remittent  in  its  character,  showing  in  its  rises  a  temperature  of 
103°  or  upward,  and  at  times  with  a  well-defined  swelling,  which 

46 


722  MEDICAL    DIAGNOSIS. 

may  be  felt  in  the  lumbar  region  and  extending-  far  downward. 
All  this  is  very  different  from  Bright's  disease,  which  always 
affeets  both  kidneys,  and  in  which  no  enlargement  of  the  organs 
can  be  perceived  through  the  abdominal  walls.  Then,  we  detect 
blood  and  pus  in  the  urine  of  cases  of  suppurative  nephritis,  and 
any  casts  that  are  found  are  seen  to  be  covered  with  pus-corpuscles. 

Hsematuna  and  Purulent  Urine. — In  botli  these  complaints,  if 
we  can  speak  of  them  as  such,  there  is  albumen  in  the  urine  ;  and, 
on  the  other  hand,  traces  of  blood  and  pus  may  be  ])resent  in  the 
urine  of  Bright's  disease.  But  the  quantity  of  albumen  met  with 
in  liaMuatnria  or  in  purulent  urine  is  small  ;  in  fact,  it  is  in  exact 
proportion  to  the  amount  of  pus  or  blood  the  urine  contains ; 
whereas,  on  the  contrary,  if  the  secretion  from  a  Bright's  kidney 
be  mixed  with  pus  or  blood,  the  amount  of  albumen  is  large. 

Simple  Albuminuria. — By  this  is  meant  an  albuminous  urine 
unconnected  with  any  marked  structural  lesion,  unless  congestion, 
— such  an  albuminuria  as  is  sometimes  observed  as  a  transient  phe- 
nomenon in  the  course  of  several  diseases ;  as,  for  instance,  in  the 
exanthemata,  in  typhus,  in  cholera,  in  hectic  fever,  in  chronic  con- 
gestion of  the  liver,  in  oxaluria,  or  as  a  consequence  of  surgical 
diseases  and  operations.*  An  albuminuria  of  similar  kind  is  also 
met  with  when  the  kidneys  become  congested  from  interference 
with  the  circulation,  as  in  disease  of  the  heart,  or  from  the  press- 
ure of  a  gravid  womb.  Albumen  in  the  urine  mav  also  be  en- 
countered  in  erysipelas,  in  diphtheria,  in  pneumonia,  in  acute 
rheumatism  and  in  gout,t  consecutively  to  a  burn,  to  a  blister  or  a 
large  mustard-plaster,  or  to  the  use  of  salicylic  acid,  or  of  turpen- 
tine or  carbolic  acid.  But  in  all  these  conditions  the  quantity 
found  is  small  and  transitory,  very  unlike  what  it  is  in  the  per- 
sistent albuminuria  of  Bright's  disease,  and  the  urine  is  usually 
dense  and  high-colored.  Then  the  constitutional  symptoms  in  the 
morbid  states  referred  to  are  so  dissimilar  to  those  of  Bright's 
disease  that  they  become  a  safeguard  against  error. 

Yet  the  most  valuable  aid  in  forming  a  judgment  is  derived 
from  a  microscoj)ical  investigation  of  the  urinary  sediment.  In 
simple  albuminuria  there  is  no  exudation ;  hence  no  tube-casts  can 

*  Henry  Lee,  Lectures  on  Practical  Pathology  and  Surgery,  3d  ed.,  London, 
1870,  vol.  ii.  p.  380. 

f  Thudichuin  on  the  Pathology  of  the  Urine,  1877. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       723 

be  detected  in  the  urine.  This,  at  least,  represents  the  <r(;ii(;rul 
truth.  Still,  searching  examinations  may  detect  occasionally  a 
few.  Yet  their  inconstancy,  their  character,  the  small  amount  of 
albumen  they  are  commonly  associated  with,  are  of  significance ; 
and  the  general  nature  of  the  symptoms  again  helps  to  explain 
their  meaning.  Then,  too,  the  kidney  may  be  ideally,  in  several  of 
the  morbid  states  under  discussion,  in  the  same  condition  as  in 
the  earlier  stages  of  acute  Bright's  disease;  but  for  the  most  part 
it  is  simply  in  a  state  of  hypersemia,  either  active  or  more  gener- 
ally passive  from  congestion,  and  it  is  unlike  the  swollen  organ 
and  the  fully-developed  malady  with  its  marked  clinical  features. 

In  addition  to  these  forms  of  simple  albuminuria  there  is  one  of 
great  importance  to  recognize,  where  the  albumen  happens  in  per- 
sons who  in  every  respect  seem  healthy,  and  occurs  shortly  after 
partaking  plentifully  of  food,  especially  of  albuminous  food,  or 
after  severe  exercise,  particularly  in  young  persons  at  or  near  the 
age  of  puberty.  Some  of  these  cases  are  cyclic,  occurring  only  at 
certain  times  of  the  day ;  in  much  fewer,  the  albuminuria  is  per- 
sistent. In  the  great  majority  of  cases,  indeed,  there  is  a  time  in 
every  day  in  which  the  urine  is  free  from  albumen.  It  is  normal 
in  quantity,  normal  or  slightly  increased  in  specific  gravity,*  nor- 
mal in  the  amount  of  urea  it  contains,  and  no  tube-casts  are  found 
in  its  sediment,  but  uric  acid  and  oxalates  are  not  uncommon. 
The  amount  of  albumen  in  these  functional  albuminurias  is  small, 
and  there  are  no  cardio- vascular  changes ;  indeed,  there  is  no 
symptom  except  the  albuminuria  to  suggest  disease.  The  bearing 
this  form  of  albuminuria  has  on  life  assurance  is  leading  to  its 
very  careful  study. f 

Pulmonary  Oedema. — Bright's  disease  is  one  of  the  most  fre- 
quent causes  of  dropsical  effusion  into  the  air-cells  :  oppression  in 
breathing,  inability  to  lie  in  the  recumbent  position,  cough,  frothy 
expectoration,  are  therefore  common  among  the  symptoms  attend- 
ing the  renal  affection.  And,  to  distinguish  this  oedema  from  that 
produced  by  other  morbid  states,  we  have  only  to  examine  the 

*  Purdy  on  Diseases  of  the  Kidney. 

t  See  especially,  among  recent  papers,  Grainger  Stewart,  "  On  Some  Forms 
of  Albuminuria  not  Dangerous  to  Life,"  Amer.  Journ.  Med.  Sci.,  Jan.  1887; 
and  Tyson,  "  The  Eelation  of  Albuminuria  to  Life  Assurance,"  Medical  News, 
Nov.  17,  1888. 


724  MEDICAL    DIAGNOSIS. 

uriiK'  oareriilly, — a  matter,  indeed,  wliieli  ought  nut  to  be  neglected 
in  any  case  of  oedema  of  the  lungs.  Yet  we  must  not  forget  that 
small  amounts  of  albumen  may  be  found  in  urine  from  any  stress 
of  breathing,  and  from  diseases  that,  like  those  of  the  heart,  con- 
gest the  lungs  and  kidney  and  arc  themselves  among  the  causes 
of  pulmonary  adema. 

l^ericarditis  and  Pleuritis. — The  tendency  to  inflammations  of 
the  serous  membranes  is  a  remarkable  peculiarity  of  Bright's  dis- 
ease. We  may  discriminate  pericarditis  or  pleuritis  complicating 
the  malady  from  either  of  these  affections  of  other  origin,  by  noting 
the  far  greater  amount  of  dropsy  than  is  ordinarily  found  in  these 
disorders,  and  by  detecting  albumen  and  tube-casts  in  the  urine. 

Dropsy. — By  an  examination  of  the  urine,  too,  may  be  dis- 
tinguished the  dropsy  of  the  complaint  under  consideration  from 
that  produced  by  other  causes.  And  we  also  see  very  often  the 
evidences  of  the  true  nature  of  the  dropsy  in  its  beginning  with 
swelling  of  the  face  and  then  becoming  universal,  and  in  the 
striking  and  characteristic  physiognomy  which  it  has  a  share  in 
developing. 

Coma ;  Convulsions. — A  dangerous  complication  of  Bright's 
disease  manifests  itself  by  drowsiness  and  convulsions.  Now,  it 
is  very  important  to  distinguish  the  cases  produced  by  urremic 
poisoning  from  epileptiform  convulsions  and  kindred  states  in 
which  there  is  no  appreciable  change  of  structure  in  the  kidneys. 
Let  us  see  how  they  differ. 

U)'ivmia,  or  uroemic  intoxication,  is  commonly  preceded  by  a 
diminution  in  the  urinary  secretion.  There  is  headache,  with  in- 
distinct vision,  great  drowsiness,  and  vertiginous  sensations ;  the 
pupils  are  sluggish  and  usually  dilated;  the  hearing  is  impaired; 
the  countenance  is  dusky ;  the  skin  is  co©l,  with  short  exacerba- 
tions of  heat;  and  the  patient  suffers  from  constipation,  nausea,  and 
obstinate  vomiting.  Paralysis  of  sensation  may  be  observed  in  the 
extremities,  and  various  kinds  of  cutaneous  eruptions.  The  dul- 
ness  of  mind  is  apt  to  deepen  into  stupor  or  coma,  or  convulsions 
set  in  as  precursors  of  the  coma,  which  terminates  in  death  unless 
the  urinary  secretion  be  freely  re-established.  The  coma  may  at 
one  time  be  so  profound  that  it  is  impossible  to  arouse  the  patient, 
whilst  at  another  time  he  rouses  himself  and  acts  with  intelligence. 
The  convulsions  generally  succeed  one  another  rapidly. 


THE    URINE,  AND    DISEASES   OF   THE    URINARY    ORGANS.       725 

In  some  cases  the  marked  phenomena  set  in  with  a  chill ;  in 
other  cases  there  is  no  such  obvious  beginning.  And  as  regards 
the  decided  lessening,  or  even  suppression,  of  the  urinary  secre- 
tion, though  this  is  the  rule,  it  is  not  constant.  I  have  known 
many  an  error  in  diagnosis  to  be  committed,  and  the  symptoms 
of  uraemia  many  a  time  to  receive  an  erroneous  interpretation, 
from  supposing  that  uraemia  could  not  exist,  as  the  quantity  of 
urine  passed  was  about  normal.  We  must  test  for  urea  and 
the  other  urinary  ingredients,  which  may  be  profoundly  changed 
in  amount,  notwithstanding  the  seemingly  healthy  aspect  of  the 
secretion,  and  notwithstanding,  too,  that  it  may  be  found  free 
from  albumen. 

Cases  of  ursemic  coma  differ  from  ordinary  comatose  conditions, 
as  witnessed  in  apoplexy,  in  fevers  of  a  low  type,  or  following 
narcotic  poisoning,  by  the  dissimilar  symptoms  ushering  them  in. 
The  coma  is  much  more  suddenly  developed  than  that  in  fevers ; 
far  less  suddenly  than  that  of  apoplexy  or  narcotic  poisoning.* 
Then,  the  stertorous  respiration,  to  adopt  the  observation  of  Addi- 
son,t  is  peculiar :  the  loud  sounds  of  the  expired  air  are  of  much 
higher  key,  not  like  the  low,  guttural  tones  of  apoplexy.  Fur- 
thermore, we  may  have  in  the  general  dropsy  a  clue  to  the  nature 
of  the  case ;  but  of  course  the  most  certain  light  is  thrown  on  it 
by  the  analysis  of  the  urine. 

The  same  remarks  apply  to  the  delirium  or  to  the  epileptiform 
convulsions  of  uraemia.  Here  the  difficulty  in  diagnosis  is  in- 
creased by  the  first  seizure  often  happening  unexpectedly, — so 
much,  in  truth,  increased,  that,  unless  we  are  aware  of  the  his- 
tory of  our  patient  and  have  previously  examined  the  urine,  the 
true  explanation  of  the  symptoms  is  not  to  be  reached.  Ursemic 
delirium  is  rare,  but  I  have  met  with  it  under  circumstances  in 
which  nothing  preceded  it  to  indicate  its  nature.J  Cases  of  acute 
ursemic  mania  may  also  originate  thus  suddenly.  Cases  of  urse- 
mic convulsions  may  occur  in  pregnant  women ;  in  them,  however, 

*  There  may,  however,  be  exceptions  to  this  rule,  as  was  the  case  in  a 
curious  instance  reported  by  Moore  in  the  London  Medical  Gazette,  1845, 
in  which  a  person  became  comatose  after  taking  laudanum,  yet  his  death 
was  found  to  have  been  caused  by  contracted  kidneys. 

f  Guy's  Hospital  Keports,  1859. 

X  Case  at  the  Pennsylvania  Hospital,  April,  1865. 


726  MEDICAL   DIAGNOSIS. 

the  tondenoy  to  disorder  of  tlie  kidney  is  so  great  that  we  are 
rarely  in  error  in  coneliiding  et)nvulsions  to  be  of  uraniiic  origin. 
We  must,  however,  here,  as  in  all  eonvulsions,  be  certain  that  we 
do  not  mistake  effect  for  cause.  A  slight  amount  of  albumen 
may  follow  violent  convulsions  in  epileptic  seizures.  The  tem- 
perature in  uremic  convulsions  is  said  by  Bourneville  to  be  low  ; 
but  this  is  denied  by  Bartels,  who  notes  it  as  considerably  elevated.* 

Amono-  the  other  marked  nervous  manifestations  of  ursemia 
may  be  persistent  headache,  anesthesia,  and  palsies  of  ura^mic 
origin. I 

The  cause  of  uraemia  is  still  unsettled  :  a  contamination  of  the 
blood  by  retained  poisonous  urinary  ingredients  we  may  fairly 
assume  as  always  happening,  though  these  may  be  of  different 
kinds.  The  fact  that  the  grave  j^hcnomena  are  thought  by  some 
to  be  due  to  the  urea,  by  others  to  its  decomposition  into  ammonium 
carbonate,  has  been  already  mentioned.  See  has  suggested  that 
they  may,  in  different  cases,  be  owing  to  either,  and  has  indicated 
the  features  by  which  ursemia  may  be  distinguished  from  amnio- 
nieemia.  In  the  former  there  is  no  fever ;  a  clean  tongue ;  a 
smooth,  elastic  skin  ;  a  disordered  respiration,  but  not  a  dis- 
ordered circulation ;  convulsions  and  coma.  In  the  latter  we 
always  find  mucus  or  pus  in  the  urine,  and  an  affection  in  conse- 
quence of  which  the  urine  is  retained  somewhere  in  the  urinary 
passages ;  there  are  chills,  followed  by  burning  heat  of  surface ; 
a  dry,  grayish  skin,  exhaling,  like  the  breath,  an  ammoniacal 
odor  ;  a  dry  tongue  ;  emaciation  ;  rarel}^  vomiting  ;  the  respiration 
is  free,  the  circulation  deranged  ;  headache  occurs,  but  the  intelli- 
gence remains  good.  Ursemia  always  bespeaks  retained  urinary 
ingredients ;  it  has  been  attributed  to  the  salts  of  potassium  accu- 
mulating in  the  blood.;}; 

Chronic  Bright's  Disease. — An  acute  attack  of  Bright's 
disease  may  gradually  pass  into  a  confirmed  malady,  or  the  com- 
plaint may  come  on  insidiously  and  develop  itself  slowly.  In 
either  case  we  have  a  dangerous  chronic  affection  established. 

The  transition  from  the  acute  to  the  chronic  disease  is  indicated 


*  Ziemssen's  Cyclopaedia. 

t  Laguel,  Journ.  de  Med.  et  de  Chir.  Prat.,  Oct.  1888. 

I  Feltz  et  Kitter,  De  rUremie  experimentelle,  Pari.s,  1881. 


THE    URINE,  AND    DISEASES    OF   THE    URINARY    ORGANS.       727 

by  the  disappearance  of  blood  from  tlie  urine,  by  its  lessened  spe- 
cific gravity  and  the  smaller  amount  of  albumen  it  contains,  by 
the  temperature  becoming  normal,  and  not  uncommonly  by  a  tem- 
porary diminution  of  the  anasarca  and  an  increase  in  the  quantity 
of  urine  voided. 

"  When  the  disease  runs  a  more  or  less  chronic  course  from  the 
beginning,  its  initiatory  steps  are  obscure.  'We  generally  find 
such  cases  in  persons  who  are  poorly  fed  and  half  clad,  who  live 
in  damp,  ill-ventilated  houses,  who  are  intemperate,  or  who  have 
been  subject  to  great  grief  or  worry,  or  who  are  saturated  with 
malaria,  or  whose  constitutions  are  ruined  by  syphilis  or  by  scrof- 
ula. The  first  symptoms  they  notice  may  be  frequent  desire  to 
urinate ;  swelling  of  the  extremities  or  of  the  face ;  increasing 
pallor  and  general  debility ;  and  headache,  especially  occipital 
headache.  An  examination  of  the  urine  reveals  at  once  the  cause 
of  their  protracted  indisposition.  Yet  the  renal  disease  may  lead 
suddenly  to  a  fatal  termination  without  the  patient  having  pre- 
viously experienced  any  manifest  signs  of  ill  health.  And  even 
after  the  malady  has  been  fully  recognized,  it  is  difficult  to  predict 
its  course.  We  meet  in  many  with  the  same  phenomena  as  those 
encountered  in  the  acute  variety,  except  the  fever.  But  in  others 
the  signs  are  dissimilar, — the  dropsy,  for  instance,  is  slight  or  is 
wholly  wanting.  The  only  constant  and  characteristic  manifesta- 
tions are  the  profound  and  increasing  anaemia,  and  the  presence  of 
albumen  and  tube- casts  in  the  urine. 

Generally,  the  urine  is  of  low  specific  gravity,  dependent  upon 
a  diminution  of  the  urinary  solids.  The  urea  is  lessened,  and  so 
are,  as  a  rule,  the  uric  acid,  the  pigment,  and  the  salts.  Com- 
monly, also,  the  urine  is  not  so  abundant  as  in  health,  and  its 
reaction  is  less  acid.  The  albumen  is  very  variable  in  amount ; 
its  quantity  may,  indeed,  fluctuate  much  in  the  same  patient,  and 
even  change  from  day  to  day.  It  is  persistent ;  yet  it  may,  in 
some  eases,  disappear  for  a  short  time. 

The  tube-casts,  too,  are  not  uniform, — not  nearly  so  much  so  as 
in  the  acute  variety  of  the  affection.  We  meet  with  casts  almost 
or  quite  homogeneous,  and  small  or  large ;  with  casts  besprinkled 
with  shrivelled  degenerating  epithelium ;  with  casts  covered  with 
granules  or  with  oil-drops.  In  the  progress  of  a  particular  case, 
nearly  all  these  forms  may  be  encountered,  although,  as  we  shall 


728  MEDICAL    DIAGNOSIS. 

hereafter  see,  the  preponderance  of  any  one  of  them  affords  an  in- 
dication as  to  the  exact  state  of  the  kidneys.  There  is  only  one 
kind  we  do  not  find  in  the  chronic  disorder:  the  one  covered  w'ltli 
■\vell-developed  epithelial  cells  or  blood-corpuscles.  The  apparent 
absence  of  casts  from  albuminous  urine  is  not  absolute  proof  of  the 
non-existence  of  renal  defeneration.  In  some  cases  their  absence 
is  only  temporary,  while  in  others  they  are  small  and  ivw  in  num- 
ber and  easily  escape  detection. 

From  these  remarks,  it  is  obvious  that  a  great  diversity  of  phe- 
nomena is  witnessed  in  chronic  Bright's  disease:  so  great,  in  truth, 
is  this  diversity  that  the  opinion  is  adopted  that  there  are  several 
distinct  pathological  affections  embraced  under  the  one  term,  and 
attempts  have  been  made  to  define  accurately  the  train  of  symp- 
toms significant  of  each.  But,  notwithstanding  that  a  means  of 
separation  is  also  afforded  by  tlie  very  varied  aspect  of  the  organ, 
it  is  best  to  consider  the  differential  diagnosis  of  chronic  Bright's 
disease  continuously,  pointing  out,  after  having  done  so,  the  clini- 
cal features  that  are  indicative  of  the  various  forms  of  the  malady. 

Leaving  out  of  consideration  those  affections  for  which  both 
the  acute  and  the  chronic  disease  may  be  mistaken,  and  which 
have  been  already  discussed,  chronic  Bright's  disease  may  be 
confounded  with — 

Anemia  ; 

Neuralgia  ; 

Chronic  Rheumatism  ; 

Chronic  Bronchitis; 

ASTHilA  ; 

Cardiac  Dropsy  ; 

Gastro-Intestinal  Disorders  ; 

Cancer  ;  Tuberculosis  ;  Cysts  of  Kidney  ; 

Chronic  Consecutive  Nephritis  ; 

Renal  Inadequacy. 

Ansemia. — There  are  few  diseases  which  alter  the  blood  so  com- 
pletely as  does  chronic  Bright's  disease.  The  blood-corpuscles  go 
on  steadily  diminishing,  while  the  fibrin  holds  its  own,  and  the 
quantity  of  albumen  fluctuates  considerably,  being  ordinarily  much 
reduced.  Besides  these  changes,  the  blood  often  retains  its  effete 
ingredients,  since  the  kidneys  are  incapable  of  performing  their 
function.       The   alteration   and  gradual  impoverishmeut  of  the 


THE   URINE,  AND   DISEASES   OF   THE   URINARY   ORGANS.      729 

blood  make  themselves  manifest  by  the  increasing  de]>ility,  and 
by  the  pallor  and  waxy  look  of  the  countenance. 

We  may  discriminate  this  anaemic  or  chlorotic  condition  from 
that  unconnected  with  renal  disease  by  the  existence  of  albumen 
and  tube-casts  in  the  urine,  and  often  also  by  the  prominence  of 
the  dropsical  symptoms.  But  it  is  essential  to  know  that  some 
of  the  phenomena — certainly  albuminous  urine  and  dropsy — may 
attend  the  anaemia  following  profuse  or  frequently-repeated  hem- 
orrhages, without  the  structure  of  the  kidneys  having  been  im- 
paired. It  is  difficult  to  distinguish  these  cases  from  true  Bright's 
disease,  except  by  taking  into  account  the  diminution  of  the  albu- 
men as  the  Iiemorrhagic  tendency  is  lost,  and  the  absence  of  the 
tube-casts.  The  dropsy,  unless  it  be  considerable,  can  hardly  be 
looked  upon  as  a  valuable  differential  index,  for  a  slight  or  moder- 
ate amount  of  dropsy,  or  even  none  at  all,  may  be  encountered  in 
either  morbid  state.* 

The  ophthalmoscopic  appearances  presented  by  the  retina,  and 
described  in  a  previous  part  of  this  work,  afford  help  in  distin- 
guishing between  the  anaemia  of  Bright's  disease  and  that  pro- 
duced by  any  other  cause.  Albuminuric  retinitis  is  not  limited 
to  any  form  of  Bright's  disease.  It  generally  happens  in  both 
eyes,  and,  though  in  the  chronic  variety  of  the  malady  it  may 
greatly  improve,  it  does  not  disappear.  The  sight  itself  deteri- 
orates; and  we  have  attacks  of  blindness,  ursemic  amaurosis, 
which  come  on  suddenly  and  pass  off  suddenly. 

Neuralgia. — As  this  is  not  infrequent  in  the  chronic  form  of 
Bright's  disease,  we  must  always,  in  obstinate  cases  of  neuralgia, 
examine  the  urine.  Neuralgia  of  renal  origin  may  affect  the  fifth 
nerve,  or  other  nerves  ;  sometimes  it  takes  more  the  form  of  hemi- 
crania,  and  it  is  often  associated  with  disordered  vision,  or  with 
impairment  of  other  special  senses  ;  or  it  may  coexist  with  per- 
sistent headache  or  with  strange  and  anomalous  nervous  symp- 
toms. Headache  from  Bright's  disease  may  also  be  present  with- 
out neuralgia ;  it  may  be  of  the  nature  of  megrim,  and  occur  in 
paroxysms  attended  with  nausea  and  vomiting. 


*  The  occurrence  of  marked  albuminuria  after  hemorrhage,  to  which 
attention  was  here  called,  has  been  since  studied  by  Fischl,  Arch.  f.  Klin. 
Med.,  Bd.  xxix.,  and  by  Quincke,  i6.,  Bd.  xxx.,  No.  4. 


730  MEDICAL    DIAGNOSIS. 

Chro)ii(.'  Bhcumafisiii. — Frequently  patients  affeeted  M'ith  chronic 
Bri<2;ht's  disease  complain  of  nniscular  pains.  The  i)ain  is  dull, 
not  increased  on  pressure ;  sometimes  shooting,  more  like  that 
Avhicli  is  ordinarily  called  neuralgic,  and  to  which  "\vc  have  just 
called  attention.  Tlie  pain  is  oftenest  met  with  in  those  instances 
in  ^\■hich  the  dropsy  is  slight  or  wholly  wanting,  and  an  exami- 
nation of  the  urine  is  then  the  only  means  of  determining  its  real 
significance. 

Chronic  Bronchifis. — This  is  one  of"  the  most  common  com- 
plications of  Bright's  disease, — so  common,  indeed,  that  Rayer 
observed  it  in  seven-eighths  of  his  patients,  and  Wilks*  states  it, 
from  an  extensive  analysis  of  cases,  to  have  been  more  universal 
than  any  t)ther  single  symptom,  albuminous  urine  alone  excepted. 
It  is  hardly  necessary  to  add  that  the  last-mentioned  sign  is  the 
one  that  distinguishes  this  secondary  pulmonary  affection  from  all 
other  forms  of  bronchial  disease. 

Asthma. — AYhether  or  not  there  be  coexisting  bronchitis,  attacks 
of  shortness  of  breath,  like  paroxysms  of  asthma,  occur  as  the 
result  of  Bright's  disease.  This  renal  asthma  is  most  common  in 
the  chronic  contracted  kidney.  It  has  no  features  by  which  it 
can  be  recognized  from  ordinary  asthma,  except  that  the  wheezing 
and  the  rales  are  not  so  marked,  and  that  it  does  not  subside  by 
copious  expectoration.  It  indeed  more  resembles  cardiac  asthma, 
and  is  most  frequent  at  night. 

Let  us  suppose  that  in  cases  of  so-called  cardiac  dropsy  we  find 
albumen  in  the  urine :  is  this  a  proof  of  coexisting  Bright's 
disease?  Not  unless  the  amount  of  the  abnormal  ingredient  be 
considerable  and  more  than  occasional-  tube-casts  accompany  the 
albuminuria.  Mere  congestion  of  the  kidneys,  resulting  as  it 
does  from  an  obstruction  to  the  flow  of  the  venous  blood  along 
the  vena  cava,  may  occasion  albuminuria ;  but  the  presence  of 
albumen  is  temporary,  and  its  quantity  small,  and  the  specific 
gravity  of  the  urine  is  generally  high.  A  large  amount  of  albu- 
men, persistent  and  conjoined  with  characteristic  tube-casts,  shows 
that  changes  are  present  in  the  renal  textures.  Disease  of  the 
heart  and  disease  of  the  kidney  are  often  combined.  It  is  the 
disease  of  the  kidney  which  produces  or  coexists  with  the  dis- 

*  Guy's  Hospitiil  lleports,  2d  Series,  vol.  viii. 


THE   URINE,  AND    DISEASES   OF   THE   URINARY   ORGANS.      731 

ease  of  the  heart.  The  cardiac  aiFection  does  not  give  rise  to 
the  renal  affection  nearly  as  often  as  supposed.* 

Gastro- Intestinal  Disorders. — These  are  among  the  most  com- 
mon consequences  of  the  renal  malady.  They  manifest  themselves 
in  various  ways:  by  flatulency  and  indigestion;  by  diarrhoea;  by 
nausea  and  vomiting.  The  latter  symptoms  are  apt  to  occur  when 
uremic  intoxication  is  developed.  They  may  be,  however,  also 
met  with  at  any  period  of  the  disease  without  the  concurrence  of 
other  urgent  symptoms,  and  become  so  prominent  as  to  throw  into 
the  background  most  of  the  other  signs  of  the  renal  aiFection.  I 
have  seen  cases  of  Bright's  disease  which  first  manifested  them- 
selves by  apparently  causeless  nausea  and  vomiting ;  the  tongue 
was  clean. 

Cancer ;  Tubercle;  Cysts  of  Kidney. — These  morbid  products 
affect  the  kidneys  but  rarely, — at  all  events,  rarely  in  a  form  so 
marked  as  to  give  rise  to  conspicuous  clinical  phenomena.  In  all 
of  them  there  may  be  albumen  present  in  the  urine,  but  it  is  gen- 
erally in  small  amounts,  and  mixed  with  some  ingredient  having 
a  more  specific  meaning.  Thus,  in  cancer  of  the  kidney  we  may 
find  blood  with  the  albumen  ;  indeed,  hsematuria  is  a  very  impor- 
tant symptom,  and  in  some  instances  we  discern  with  the  micro- 
scope cells  like  those  observed  in  any  cancerous  growth  ;  often  the 
hemorrhages  are  profuse  and  frequently  recurring,  are  preceded 
by  severe  pain,  and  we  detect  a  palpable  tumor  in  the  flank, 
passing  upward  into  the  hypochondriac  region  and  downward 
to  the  iliac  region,  or  even  forward,  not  affected  by  the -act  of 
breathing,  and  sometimes  causing  bulging  posteriorly.  In  cases 
of  melanotic  cancer,  whether  it  have  its  seat  in  the  urinary  ap- 
paratus or  elsewhere,  Eiselt  and  Bolzef  have  noticed  that  the 
urine  on  standing  assumes  the  color  of  porter,  and  that  on  the 
addition  of  concentrated  nitric  acid  it  instantly  presents  the  same 
dark  color.  In  children,  cancer  of  the  kidney  is  not  a  rare  dis- 
ease,! ^^^^  when  we  can  exclude  as  the  cause  of  the  renal  tumor 
cystic  degeneration  and  hydronephrosis — in  them  congenital  affec- 

*  See  proof  in  Middleton-Goldsmith  Lecture,  1888,  or  Eelation  of  the  Dis- 
eases of  the  Kidney,  especially  the  Bright's  Diseases,  to  Diseases  of  the  Heart, 
hy  J.  M.  Da  Costa. 

f  Prager  Vierteljahrschr.,  vols.  lix.  and  Ixvi. 

J  Braidwood,  Liverpool  Keports,  1870. 


732  MEDICAL    DIAGNOSIS. 

tions — we  can  (liasnosticate  the  case  with  some  confidence.  In 
adults  the  diagnosis  is  alwavs  doubtful,  at  least  when  the  disease 
is  primary.  A  rapid  and  irregular  growth  of  the  one-sided  renal 
tumor,  severe  pain,  bloody  urine,  and  cachexia  are  the  most  certain 
signs.  Sudden  and  rapidly-growing  varicocele  is  stated  to  be  a 
symptom  of  malignant  tumor.*  Sijpliilomata  of  the  kidney  may 
be  suspected  from  the  history,  but  cannot  be  recognized  with  cer- 
tainty;  they  rarely  cause  pain  or  produce  a  tumor  large  enough 
to  be  detected,  but  mainly  give  rise  to  the  ordinary  manifestations 
of  clironic  Bright's  disease,!  most  often  of  the  amyloid  form.  In 
Horcoma  of  the  kidney  the  swelling  in  the  abdomen  attains,  in  chil- 
dren especially,  very  great  size ;  hannaturia  is  com [)a rati vely  rare, 
and  the  peripheral  lymphatic  glands  do  not  become  implicated.J 

In  tubercle,  little  yellow  cheesy  masses  of  degenerated  tuber- 
cular matter  collect  as  a  sediment,  as  in  the  cases  referred  to  by 
Frerichs  in  his  work  on  Bright's  disease.  The  constant  presence 
of  this  sign  is,  however,  doubtful.  The  tubercular  matter  is 
derived  from  the  ureters  or  pelvis  of  the  kidneys.  The  deposit 
it  forms  in  the  urine  is  insoluble  in  acetic  acid;  and  Vogel  de- 
scribes the  microscopical  characters  of  the  deposit,  as  irregular 
corpuscles  not  exhibiting,  when  treated  with  acetic  acid,  normal 
nuclei,  or  showing  only  small,  irregular  nucleoli,  and  an  ill-dcfincd 
detritus,  with  fragments  of  cells  and  an  indistinct  and  finely- 
granular  mass,  with  which  crystals  of  cholesterin  are  sometimes 
mingled.  Pus  and  other  signs  of  chronic  pyelitis  are  also  pres- 
ent, and  there  is  no  other  assignable  cause  for  the  existence  of  the 
suppurative  disease  than  tubercle.  We  may  be  assisted  in  the 
diagnosis  by  finding  tubercles  in  other  organs.  Rayer  tells  us 
that  scrofulous  disease  of  the  vertebrae  has  repeatedly  been  ob- 
served to  be  associated  with  tubercular  kidneys.  In  tubercle  of 
the  kidney,  extreme  pain,  occurring  in  paroxysms  like  those  of 
nephritic  colic,  is  a  very  important  sign.  This  pain,  as  I  have  had 
occasion  to  observe,  is  associated  with  frequent  micturition,  and 
is  temporarily  relieved  by  the  flow  of  water.  The  urine  is,  how- 
ever, scanty.    A  moderate  amount  of  ha^maturia  may  happen  ;  the 

*  Guillet,  Tumeurs  malignes  des  Reins,  These  de  Paris.  1888. 
t  Wagner,  Archiv  f.  Klin.  Med.,  Bd.  xxviii.,  1881  ;  Mauriac,  Arch.  Gen. 
de  Med.,  Oct.  1886 ;  Jaccoud,  Gaz.  des  Hop.,  1888. 
X  Neumann,  Archiv  f.  Klin.  Med.,  Bd.  xxx.,  1882. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       733 

patient  passes  at  times  little  fibrinous  shreds,  and  emaciates  stead- 
ily. The  bacillus  of  tubercle  may  serve  as  a  means  of  diagnosis 
in  the  urine ;  it  has  been  detected  in  a  number  of  instances.* 

Cheesy  inflammation  of  the  kidney  is  separated  by  many  from 
tubercle,  with  which  it  may  or  may  not  coexist.  The  nephro- 
phthisis  is  met  with  oftener  in  men  than  in  women,  and  the 
caseous  inflammation  may  begin  in  the  mucous  membrane  of  the 
bladder,  or  in  the  prostate,  and  extend  to  the  kidney.f  .  The  urine 
is  generally  acid,  and  small  cheesy  masses,  elastic  fibres,  and  shreds 
of  cast-oflt'  connective  tissue  may  be  found.  A  renal  tumor  can 
rarely  be  detected. 

In  cysts  of  the  kidney — those  at  least  enclosing  echinococci 
— small  vesicles  containing  the  characteristic  structures  of  the 
parasites  may  perhaps  be  detected.  Ordinary  cysts  are  not  to  be 
recognized  with  any  certainty  during  life ;  nor  can  they  be  dis- 
tinguished from  Bright's  disease,  since  they  are  very  frequently 
developed  in  the  chronic  varieties  of  this  disorder.  When  the 
cysts  attain  decided  dimensions,  they  give  rise  at  times  to  the  dis- 
charge of  highly-bloody  urine,  and  to  albuminuria,  and  to  large 
tumors,  which  may  be  detected  through  the  front  walls  of  the 
abdomen.  They  may  affect  one  or  both  kidneys,  producing  slow 
cachexia  and  enormous  abdominal  swelling.  Cysts  of  the  kidney 
and  liver  often  coexist.^ 

Chronic  Consecutive  Nepkritis. — In  consequence  of  afPections  of 
the  bladder,  of  stone  in  the  bladder,  of  strictures  of  the  urethra, 
of  disease  of  the  ureters  and  of  the  prostate,  indeed  of  various 
surgical  affections  of  the  urinary  organs,  we  may  have  a  kidney 
disease  established  which  is  rather  a  form  of  slow  inflammatory 
change  than  Bright's  disease.  It  may  affect  only  one  or  both 
kidneys,  and  the  diseased  organs  are  tough  and  hard,  large  or 
small,  and  show  great  increase  of  fibrous  tissue.  The  source  of 
irritation  which  has  led  to  the  secondary  inflammation  is  at  times 
in  the  kidney  itself,  in  the  shape  of  a  large  calculus  in  the 
pelvis. 

In  another  form  of  this  consecutive  nephritis  suppuration  takes 

*  E.  Shingleton  Smith,  Lancet,  i.  942,  1883  ;  Irsai,  Wien.  Med.  Presse, 
p.  1173,  1884. 

I  Ebstein,  Diseases  of  the  Kidneys,  in  Ziemssen's  Cyclopaedia. 
%  Sabourin,  Arch,  de  Phys.,  ix.,  1882. 


734  MEDICAL   DIAGNOSIS. 

place,  affecting  more  especially  the  pelvis  of  the  kidney,  a  sup- 
purative pyelo-nephritis, — the  condition  often  called  "surgical 
kidney."  It  is  difficult  to  distinguish  these  consecutive  forms  of 
nephritis,  especially  where  pus  is  found  in  the  urine,  either  from 
the  condition  last  mentioned  or  from  coexisting  bladder  disease, 
except  by  the  history.  Very  often  there  is  pain  along  the  course 
of  the  ureter ;  and  the  urine,  when  passed  free  from  pus,  contains 
neither  albumen  nor  casts,  or  only  a  small  amount  of  albumen 
and  a  few  hyaline  casts.  The  urine  is  apt  to  be  copious  and  of 
low  specific  gravity.  AVhen  it  contains  pus  from  the  kidneys, 
and  the  bladder  is  comparatively  unaffected,  the  purulent  urine 
is  aenerallv  acid.  The  heart  rarelv  becomes  disturbed,  though 
hypertrophy  has  been  occasionally  noticed  in  the  non-suppurative 
form.* 

Benal  Inadequacy. — There  are  patients  who  pass  the  ordinary 
amount,  or  loss  than  the  ordinary  amount,  of  urine  daily,  of  low 
specific  gravity,  from  1002  to  1008,  not  containing  more  than  two 
per  cent,  of  urea,  though  the  uric  acid  may  be  normal,  and  who  in 
consequence  of  this  insufficient  action  of  the  kidneys  are  always 
ailing  and  weak,  take  cold  easily,  and  suffer  from  headache  and 
nervousness.  Even  if  they  drink  water  freely,  they  do  not  pass 
more  urine;  this  does  not  contain  albumen  or  casts,  differing  in 
this  respect  from  Bright's  disease.  But  dropsy,  as  Sir  Andrew 
Clark,  who  first  described  the  complaint,t  states,  with  puffy  face 
and  dry,  glossy  skin,  may  happen,  and  a  state  similar  to  myx- 
cedema  be  gradually  developed. 

Having  now  treated  of  chronic  Bright's  disease  as  one  affection, 
I  shall  briefly  refer  to  the  distinctions  between  its  forms.  In  so 
doino-,  I  shall  follow  the  classification  based  on  the  diversified 
anatomical  aspect  of  the  kidneys. 

First  there  is  the  chronic  enlargement  of  the  organ,  of  which 
several  kinds  exist : 

1.  Hie  fatty  kidney.  The  kidney  is  very  large  and  fatty.  The 
deposit  may  occasion  yellow  scattered  granulations,  or  the  enlarged 
organ  is  pale,  and  mottled  by  red  vascular  patches.  The  convo- 
luted tubes  are  filled  with  oil,  accumulated  in  their  epithelial  c^Us. 


*  Fagge's  cases,  in  Practice  of  Medicine,  1886,  vol.  ii.  p.  483. 
■|-  BritisK  Medical  Journal,  vol.  i.,  1883. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       735 

The  fatty  disease  is  recognized  by  the  numerous  oily  easts,  fatty 
cells,  and  free  oil-cells  which  appear  in  the  highly-albuminous 
urine.  It  is  a  fatal  complaint,  generally  very  chronic  in  its 
course,  and  attended  with  persistent  dropsy.  This  morbid  condi- 
tion must  not  be  confounded  with  a  simply  fatty  kidney,  such  as 
is  sometimes  found  in  phthisis,  or  oftener  in  drunkards,  and  which 
is  not  associated  with  albuminous  urine.     A  certain  amount  of 

Fig.  52. 


Fatty  casts  and  epithelial  cells  filled  with  fat,  as  seen  in  the  discharge  coming 
from  a  highly-fatty  kidney. 

fatty  casts  and  fatty  cells  may  appear  in  the  urine  and  not  be 
persistent  or  indicate  the  real,  dangerous  fatty  kidney.  It  is 
thought  by  several,  by  Dickinson  especially,  that  the  fatty  kidney 
may  follow  a  high  degree  of  inflammation  in  the  acute  form  of 
Bright's  disease,  particularly  in  that  form  brought  on  by  exposure 
to  cold.  The  acute  form  attending  scarlet  fever  is  more  apt  to 
pass  into  the  large  white  kidney. 

2.  The  enlarged  chronically  inflamed  Mdney.  I  allude  to  the 
chief  form  of  the  large  white  kidney  so  frequently  mentioned  by 
English  physicians.  This  is  probably  the  chronic  non-desquama- 
tive  nephritis  of  Johnson  ;*  it  is  the  kidney  represented  by  the 
third,  fourth,  and  fifth  forms  of  Kayer's  albuminous  nephritis,t 


*  Diseases  of  the  Kidney. 

f  Traite  des  Maladies  des  Keiiis,  tome  ii.,  and  Atlas, 


736  MEDICAL   DIAGNOSIS. 

and  by  tlio  rlironie  parenehyniatous  inflammation  of  the  kidneys 
of  most  of  the  German  writers;  it  is  the  chronic  form  of  the  tnbal 
nephritis  of  Dickinson.  The  organ  is  white,  enlarged,  dense;  its 
tubes  are  iilled  with  exudation-matter,  their  walls  thickened.  The 
cortical  portion  of  the  kidney  is  pale  and  increased  in  breadth, 
evidently  full  of  an  inflammatory  deposit ;  the  medullary  cones 
retain  their  vascularity.  This  variety  of  the  malady  may  or  may 
not  follow  acute  Bright's  disease.  It  may  last  for  a  few  years, 
but  generally  terminates  unfavorably  before  that  time.  The  urine 
is  diminislied  in  urea  and  pigment,  but  the  chlorides  are  normal; 
it  contains  granular,  epithelial,  and  some  hyaline  casts,  and  a  few 
slightly-oily  easts.  The  dropsy  the  disease  occasions  is  extensive 
and  persistent,  and  there  is  usually  little  difficulty  in  tracing  it  to 
an  acute  attack.  Sometimes  the  dropsy  lessens  materially,  then 
actively  recurs,  and  there  seem  to  be  rather  a  series  of  subacute 
attacks  than  a  continuous  chronic  malady.  The  large  kidney  is 
not  supposed  ever  to  contract ;  but  this  is  not  a  settled  point. 
Grainger  Stewart  holds  that  it  does,  as  does  the  waxy  kidney,  yet 
believes  that  both  in  a  stage  of  atrophy  are  distinct  from  the  so- 
called  cirrhotic  or  contracting  form  of  Bright's  disease.*  The 
large  white  kidney  may  pass  into  the  fatty  kidney.  Dilatation 
of  the  heart  is  common  in  chronic  parenchymatous  nephritis, 
more  common  even  than  pure  hypertrophy,  which  is  more  usual 
in  contracted  kidney. 

3.  The  waxij  or  amyloid  Tddney,  an  aifection  in  which  the  en- 
larged organ  is  smooth,  of  firm  look,  and  of  pale-yellow  color,  and 
is  the  result  of  a  general  disease  involving  the  kidneys  in  common 
with  other  organs.  It  originates  in  the  exudation  from  the  mi- 
nute arteries  of  a  waxy  material  which  infiltrates  the  tissues.  This 
disease  very  generally  follows  upon  protracted  suppuration  from 
whatever  cause,  either  wound  or  disease,  as  dysentery  or  phthisis. 
The  urine  is  increased  in  quantity  in  the  earlier  stages,  and  con- 
tains much  albumen,  but  not  many  casts.  Those  which  are  seen 
are  pale,  and  for  the  most  part  transparent,  or  highly-refracting, 
structureless  moulds  of  the  tubules,  generally  of  large  diameter ; 
they  may  or  may  not  give  the  characteristic  amyloid  reaction,  the 
red  color  when  treated  with  a  watery  solution  of  iodine  and  of 

*  On  Bright's  Disease  of  the  Kidneys,  1871. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       737 

potassium  iodide.*  Metliyl-grcen  colors  amyloid  substances  an 
intense  green.  It  is  used  for  staining  in  the  form  of  a  one  per  cent, 
aqueous  solution.  Methyl-green  colors  hyaline  casts  in  situ  ultra- 
marine blue,  so  that  these  also  can  be  readily  distinguished  in 
sections  of  the  kidney  from  the  green-colored  tissues  around,  in 
which  they  may  lie.  Blood  is  rarely  present  in  the  urine  of  the 
amyloid  kidney,  and  the  urea  is  but  slightly  diminished  in  quan- 
tity. Diarrhoea  frequently  coexists,  and  the  liver  and  spleen  are 
apt  to  be  enlarged ;  but  the  heart  is  not  affected.  The  dropsy  is 
absent  or  trifling  in  amount,  yet  its  persistence  while  the  urine  is 

Fig.  53. 


Hyaline  or  waxy  casts,  magnified  about  4G0  diameters.  On  some  of  them  are 
scattered  a  few  shrivelled  epithelial  cells  and  oil-drops;  the  large  cells  to  the 
left  are  epithelial  cells  from  the  bladder. 

The  kind  of  casts  here  depicted  may  he  found  in  any  form  of  Bi  igbt'a  disease, 
acute  as  well  as  olironic.  In  the  waxy  kidney,  however,  they  vastly  preponder- 
ate, and  are  of  large  size, — many  much  larger  tlian  those  in  this  figure. 

increased  in  quantity  is  peculiar  to  this  form  of  renal  disease,  and 
it  may  exist  markedly  as  a  late  symptom  ;  the  patient  is  sallow- 
looking  and  emaciated  ;  his  disease  may  last  for  years. 

In  laying  stress  on  the  hyaline  and  waxy  casts  we  must  be  care- 
ful not  to  confound  them  with  those  still  larger  mucous  moulds 
of  the  uriniferous  tubules,  or  mucous  casts.  They  are  also  smooth, 
but  of  enormous  length,  subdividing  into  smaller  ones,  and  of 
cylindrical  shape.     They  are  met  with  in  acute  parenchymatous 

*  Curschmann,  Virchow's  Archiv,  vol.  Ixxix.,  part  3. 

4r 


738 


MEDICAL   DIAGNOSIS. 


nephritis,  but  arc  particularly  apt  to  occur  in  consequence  of  trans- 
mitted irritation  from  tlie  bladder,  and  are  then  perhaps  associated 
M'ith  small  amounts  t»f  albumen  and  of  pus.  Yet  unless  the  latter 
ingredient,  be  present  there  is  no  albumen,  or  the  merest  trace. 
Further,  flask-shaped  hyaline  bodies  and  cylinders  may  be  moulds 
of  the  vesicles  and  smaller  ducts  of  diseased  prostates.* 

4.  Then  we  have  the  small  contracted  kidney,  the  granular  kid- 
ney or  interstitial  nephritis,  which  is  viewed  as  the  last  stage  of 
Bright's  disease  by  those  who  believe  in  the  various  appearances 

Fig.  54. 


Granular  casts,  or  ciists  covered  with  disintegrating  epithelium  and  granules. 
Casts  of  this  character  are  chiefly  found  in  the  chronic  inflammatory  forms  of 
Bright's  disease.  They  are  not  seen  in  the  acute  complaint,  e.xcept  when  it  is 
assuming  a  chronic  form. 


being  only  successive  stages  of  the  same  morbid  process,  but  which 
is  more  generally  held  to  be  an  independent  disease.  This  form 
of  disease  is  frequently  found  in  gouty  persons,  or  after  prolonged 
mental  anxiety  and  distress,t  or  as  the  result  of  lead  poisoning. 
The  urine  contains  but  an  inconsiderable  amount  of  albumen  ;  the 
tube-casts  are  granular,  or  simple  fibrinous  moulds,  generally  small, 
sometimes  large  ;  here  and  there  a  little  oil  is  observed.  Dropsy 
is  absent  in  a  certain  proportion  of  cases,  and  when  present  is 

*  Sir  Andrew  Clark,  Transactions  of  the  Clinical  Society  of  London,  vol. 
xix.,  188G. 

t  CliflPord  Allbutt,  British  and  Foreign  Medico-Chirurgical  Review,  Oct. 
1877, 


THE   URINE,  AND   DISEASES   OF   THE   URINARY   ORGANS.      739 

generally  slight.  It  often  disappears  for  a  while  and  returns. 
The  nVine  is  increased  in  quantity,  although  toward  the  ter- 
mination it  may  become  scanty  or  even  suppressed.  Dyspepsia, 
puffy  eyelids,  chronic  bronchitis,  increased  arterial  tension,  hyper- 
trophied  ventricles,  albuminuric  retinitis,  headache,  and  disorder 
of  the  nervous  system  are  common  symptoms.  The  malady  runs 
a  very  chronic  course.  It  is  chiefly  characterized  anatomically 
by  an  affection  of  the  fibrous  tissues  surrounding  the  Malpighian 
corpuscles  and  lying  between  the  tubes,  a  slow  increase,  followed 
by  a  slow  contraction,  of  the  intertubular  fibrous  tissue  and 
atrophy  of  the  tubules,  connective-tissue  changes  in  the  renal 
plexus,*  and  fibroid  changes  in  the  small  vessels  of  the  body. 
The  sphygmograph  shows  marked  pulse-tension,  and  this,  with 
altered  specific  gravity,  has  been  noticed  before  albumen  is  present 
in  the  urine.  In  the  uric  acid  or  gouty  nephritis,  uric  acid  de- 
posits may  be  found  in  the  straight  tubes  of  the  medullary  sub- 
stances. A  chronic  interstitial  nephritis  may  also  be  associated 
with  deposits  of  lime,  which  take  place  very  generally  in  the 
uriniferous  tubules  in  the  cortex.  These  lime  deposits  may  be,  as 
Virchow  points  out,  calcareous  matter  washed  into  the  kidney 
from  diseased  bone. 

In  contracted  kidney,  especially  in  the  earlier  stages,  albumen 
may  be  absent  from  the  urine,  and  we  may  have  to  recognize  the 
malady  rather  by  the  hypertrophied  heart  and  thickening  of  the 
vessels,  the  high  arterial  pressure,  and  the  ansemia.  The  urine 
may  be  of  low  specific  gravity  and  copious,  but  there  are  many 
exceptions  to  this.  Occasionally  a  few  hyaline  or  granular  casts 
are  found ;  and  the  albumen  may  not  be  entirely  absent,  but  ap- 
pears every  now  and  then  in  traces.  There  may  be  even  chronic 
general  oedema  present  without  albuminous  urine.f 

The  different  kinds  of  albumen  have  been  above  mentioned. 
Of  these  serum-albumen  and  serum-globulin  are  by  far  the  most 
important.  Indeed,  as  yet  there  has  been  nothing  of  clinical 
value  gained  by  the  study  of  the  other  varieties. 

In  the  following  table  the  clinical  difterences  between  the  various 
forms  of  Bright's  disease  are  set  forth  : 

*  Da  Costa  and  Longstreth,  Amer.  Journ.  Med.  Sci.,  July,  1880. 
t  As  in  Case  31  of  Mahomed's  paper  on  Chronic  Bright's  Disease  without 
Albuminuria,  Guy's  Hospital  Reports,  3d  Series,  vol.  xxv. 


740 


MEDICAL   DIAGNOSIS. 


Table  exhibiting  the  Clinical  Differkxces  between  the  Principal  Forms  op 

Bright's  Disease. 


Acute  Cases  in  which  Dropsy  occurs  quickli/  and  I'l 

r 


Acute  Bright's 
disease;  acute 
desquamative 
or  tubal  ne- 
phritis; acute 
parenchyma- 
tous nephritis ; 
acute  renal 
dropsy  


Caused  mostly  by 
exposure,  or  scar- 
let fever. 

Dropsy  extensive, 
generally  begins 
in  the  eyelids  or 
in  the  feet;  usu- 
ally febrile  symp- 
toms ;  uraemia 
may  be  met  with,  j 
Disease  most  com- 
mon in  childhood 
and  among  young 
adults. 

Recoveries  fre- 

quent ;  but  dis- 
ease may  termi- 
nate in  the  large 
white  kidney. 


Urine  usually 

scanty,  deep-col- 
ored, of  high 
specific  gravity, 
containing  much 
albumen,  often 
blood ;  also  blood- 
casts  ;  casts,  manj' 
of  large  size,  cov- 
ered with  epithe- 
lium, and  a  few 
hyaline  casts;  and 
free  epithelial 
cells,  cloudy  and 
granular. 


8  extensive. 

Kidneys  enlarged, 
congested  or  mot- 
tled, shedding 
epithelium;  corti- 
cal substance  in- 
creased ;  cones 
usually  redder 
than  cortical  sub- 
stance. Dilated 
convoluted  tubes, 
distended  with 
swollen,  cloudy 
epithelium  ;  at 
ends  of  tubules 
also  blood  or  plugs 
offibrin.  Tubules 
darker  and  denser 
than  normal. 


Chronic  Cases  in  which  Dropsy  is  variable  in  amount  and  may  be  absent. 


Chronic  inflam- 
matory form  ; 
chronic  tubal 
nephritis; 
chronic  paren- 
chymatous ne- 
phritis ;  large 
white  kidne}'... 


f  History  often  of  an- 
tecedent acute  in- 
flammatory at- 
tack ;  dropsy  a 
prominent  symp- 
tom. Uraemic 
phenomena  not 
uncommon; 
among  them  at 
times  urasmic 
coma,  with  its 
usual  symptoms. 
Inflammations  of 
serousmembrnnes 
also  not  uncom- 
mon. 

Hypertrophy  of 
heart,  especially 
of  the  left  ven- 
tricle. 

Recovery  possible, 
but  doubtful  ; 
may  pass  into 
fatty  kidney. 


Urine  in  normal 
or  in  increased 
quantity ;  albu- 
men generally  in 
considerable 
amount ;  granu- 
lar epithelial 
casts ;  some  hya- 
line casts ;  at 
times  compound 
granule  cells  and 
partiallj'  fatty 
epithelium;  casts 
with  fragments  of 
epithelium  or  a 
little  fat;  no 
blood-casts. 


Kidneys  enlarged, 
capsules  easily 
stripped  off,  cor- 
tical substance  in- 
creased in  vol- 
ume, cones  may 
be  of  natural 
color ;  tubes  often 
irregularly  dis- 
tended, and  filled 
with  granular 
epithelium  here 
and  there  slightlj- 
fatty,  and  with 
detritus.  Thick- 
ening of  inter- 
tubular  matrix. 


THE   URINE,  AND   DISEASES   OF   THE   URINARY   ORGANS.      741 


Table  exhibiting  the    Clinical    Differences  between  the  Principal    Forms  of 
Bright's  Disease. —  Continued. 

Chronic   Cases  in  which   Dropsy  is  variable  in  amount  and  may  be  absent. — 

Continued. 


Patty       Bright's 
kidney 


Persistent  and  ob- 
stinate dropsy, 
coming  on  grad- 
ually; face  pale 
and  puffed ;  liy- 
pertrophy  of 

lieart       affecting 
often  both  sides. 

Always  fatal. 


p  Urine  contains 

much  albumen, 
fatty  casts,  fatty 
epithelial  cells, 
free  oil. 

Spec.  grav.  varia- 
ble, usually  from 
1015  to  1030. 

Quantity  variable, 
generally  mod- 
erate or  dimin- 
ished; urea  di- 
minished. 


Kidneys  enlarged, 
and  very  fatty ; 
sometimes  have  a 
mottled  look. 

The  tubes,  espe- 
cially the  convo- 
luted ones,  full  of 
highly-fatty  epi- 
thelium, and  free 
oil. 


Waxy  kidney ; 
lardaceous  or 
amyloid  de- 
generation of 
kidney 


Follows  usually  ex- 
hausting and 
wasting  diseases, 
syphilis,  caries, 
and  long-con- 
tinued suppura- 
tion. 

Rare  in  very  early 
and  in  advanced 
age. 

Dropsy  trifling,  ex- 
cept late  in  dis- 
ease ;  great  ema- 
ciation ;  striking 
sallowness  of 

face;  liver  and 
sj)leen  enlarged ; 
diarrhoea;  much 
thirst ;  heart  not 
affected ;  nervous 
symptoms  infre- 
quent. 

Unfavorable    prog- 
L       nosis. 


Urine  increased, 
contains  much 
albumen,  but  few 
easts,  which  are 
pale  and  trans- 
jjarent  or  highly 
refracting.  The 
casts  may  or  may 
not  give  the  ma- 
hogany-red re- 
action with  a 
watery  solution 
of  iodine. 

Spec.  grav.  low,  yet 
usually  above 
1010;  urea  nor- 
mal or  slightly 
diminished. 


Kidneys    enlarged, 
smooth,  and 

waxy  -  looking ; 
capsule  easily  de- 
tached ;  cortex 
pale,  anEemie; 
reddish  -  brown 
discoloration  on 
testing  with 

watery  solution 
of  iodine  ;  cones 
often  dark  and 
congested.  Mor- 
bid process  at 
first  chiefly  along 
renal  vessels. 


742 


MEDICAL   DIAGNOSIS. 


Table   exhiuiting  the  Clinical  Dippkuexces  between  the  Principal   Forms  op 
Buight's   Disease. — Cuntiuued. 

Chronic  'Caves  in  tchit-h  l/rojjuy  is  variuHc  in  timvunt  and  viai/  be  absent. —  Continued. 


Chronic  cod- 

traction  of 

the  kidney ; 
cirrhosis.  of 
the  kidney  ; 
interstitial  ne- 
phritis ;  gran- 
ular kidney  ; 
gouty  kidney. 


^  Dropsy  slight,  fre- 
quentlj'  absent; 
face  sallow,  yet 
not  so  much  so  as 
in  the  waxy  dis- 
ease; often  head- 
ache and  reten- 
tion of  urea,  teii- 

I  dency  to  coma, 
and     to    convul- 

i'  sions;  impov- 
erished blood ; 
hypertrophy  of 
]  heart;  epistaxis  ; 
liver  may  be  cir- 
rhosed;  retinitis. 
Most  common  be- 
tween forty  and 
sixty  years  of  age. 
May  exist  for  years 
unsuspected ;  is  a 
very  chronic  dis- 
ease, and  incura- 
ble; may  lead  to 
death  by  apo- 
plexy. 


Urine  more  copious 
than  in  health, 
yet  extremely 
small  amount  of 
albumen,  this  at 
times  temporarily 
absent;  hyaline 
and  large  finelj' 
granular  casts; 
altered  epithe- 
lium ;  a  little  oil. 

Spec.  grav.  low  ; 
rarely  above 

1010,  much 

oftener  below; 
urea  not  de- 
creased until  late 
in  disease. 


Kidneys  waste 

slowly,  become 
dense  and  con- 
tracted ;  capsule 
very  adherent  : 
surface  oficn 

granular;  thick- 
ness of  the  corti- 
cal substance  di- 
minished; cysts 
common.  There 
is  hypertrophy  of 
connective  tissue ; 
compression  and 
atrophy  of  gland- 
elcmcnts  and  of 
tubules.  Cardio- 
vascular changes. 
Tissucchiinges  in 
renal  ganglia. 


Diseases  associated  with  Purulent  Urine. 

In  every  case  in  which  pus  in  any  quantity  is  detected  in  the 
urine,  it  becomes  of  great  importance  to  ascertain  primarily  that 
it  is  not  derived  from  the  urethra,  from  the  vagina,  or  from  an 
abscess  that  has  opened  into  the  urinary  passages.  The  first  point 
we  may  decide  by  examining  into  the  history  of  the  case,  and,  if 
necessary,  by  an  exploration  of  the  parts,  as  well  as  by  an  exami- 
nation of  the  urine  procured  in  the  manner  recommended  in  the 
first  part  of  this  chapter;  the  second,  by  the  same  means,  and  by 
determining  that  a  discharge  takes  place  equally  when  no  urine 
is  voided;  the  third  is  more  difficult  to  make  out,  but  there  is 
generally  something  in  the  symptoms  and  in  the  history  of  the 
case  furnishing  a  clue  to  its  interpretation, — such,  for  instance,  as 
the  sudden  appearance  of  a  large  quantity  of  pus  in  the  urine. 


THE    UEINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       743 

Having  excluded  each  of  these  morbid  states  as  the  source  of 
the  purulent  urine,  we  next  turn  to  see  which  of  the  maladies  that 
are  its  most  common  cause  is  before  us.     They  are  : 

Acute  Cystitis. — Acute  inflammation  most  frequently  affects 
the  mucous  membrane  at  or  near  the  neck  of  the  bladder.  The 
inflammation  may  spread  from  the  mucous  membrane  to  the  mus- 
cular coat;  but  it  rarely  reaches  the  peritoneal  covering.  In 
some  cases  it  is  propagated  along  the  uterus,  and  even  to  the 
kidneys.  The  morbid  action  is  not  often  of  idiopathic  origin, 
although  sometimes  it  follows  exposure  to  cold  and  damp ;  much 
more  usually  is  it  due  to  the  extension  of  an  attack  of  gonor- 
rhoea, to  disease  of  the  prostate,  to  traumatic  causes,  to  protracted 
retention  of  urine,  or  to  the  irritation  produced  by  medicines 
or  stimulating  drinks.  Sometimes  it  is  owing  to  the  poison  of 
rheumatism  or  of  gout. 

Acute  cystitis  is  much  more  frequently  encountered  in  men  than 
in  women,  and  in  adults  than  in  children.  Its  main  symptoms 
are  a  feeling  of  weight  and  pain  in  the  hypogastric  region,  aug- 
mented by  movement  and  by  pressure.  The  pain  does  not,  how- 
ever, remain  confined  to  the  region  about  the  bladder,  but  is  also 
felt  in  the  iliac  and  sacro-lumbar  regions.  It  is  attended  with 
considerable  febrile  disturbance  and  extreme  irritability  of  the 
affected  viscus.  The  urine  is  voided  drop  by  drop,  and  its  passage 
is  usually  accompanied  by  straining  and  a  scalding  sensation  at 
the  neck  of  the  bladder ;  it  is  high-colored,  cloudy  from  increased 
vesical  mucus,  and  contains  blood  and  pus  and  sometimes  shreds 
of  lymph.  The  acute  disease  generally  terminates  within  a  week, 
leaving;  often  an  irritable  bladder  or  a  chronic  inflammation. 

The  symptoms  of  acute  cystitis  are  similar  to  those  of  acute 
nephritis,  and  the  exciting  causes  are  much  the  same.  But  acute  in- 
flammation of  the  bladder  differs  from  acute  inflammation  of  the 
kidney  by  the  greater  severity  of  the  pain,  its  much  lower  posi- 
tion, and  the  distress  in  voiding  the  urine.  Neuralgia,  or  spasm, 
of  the  bladder  may  be  distinguished  from  acute  inflammation  by 
the  absence  of  fever,  and  by  the  sharp,  lancinating,  but  paroxysmal 
pain,  each  onset  of  which  lasts  hardly  longer  than  from  two  to 
six  hours,  and  is  attended  with  difficulty  in  making  water,  which 
disappears  as  the  pain  subsides. 

Metritis  exhibits  several  of  the  traits  of  cystitis :  we  find  the 


744  MEDICAL    DIAGNOSIS. 

siuno  hypogastric  pain  shot)ting-  to  the  tliighs  or  to  tlio  anus  and 
loins,  the  same  feeling  of  weight  in  the  peritoneum,  and  the  same 
signs  of  irritation  of  the  bladder  and  of  fever.  As  it,  however, 
generally  oeeurs  in  the  puerperal  state,  Me  have  the  history,  and 
the  character  of  the  discharges  from  the  vagina,  to  guide  us,  as 
well  as  the  knowledge  to  be  gained  by  a  local  exauiinalion. 

Chronic  Cystitis. — This  aifection,  often  called  chronic  vesical 
catarrh,  is  common  in  advanced  age.  It  generally  comes  on  in 
an  insidious  manner,  and  is  excited  by  some  obstacle  to  the  evacu- 
ation of  urine,  such  as  a  stricture,  or  by  the  presence  of  a  stone 
in  the  bladder,  or  by  an  enlargement  of  the  prostate  gland.  A 
paralysis  of  the  viscus  leading  to  retention  of  its  contents,  or  a 
serious  structural  disease  of  its  coats,  whether  malignant  or  non- 
malignant,  may,  however,  also  establish  the  morbid  process. 

The  symptoms  are  partly  those  of  constitutional  debility,  partly 
those  of  local  disease.  The  most  usual  of  the  latter,  indeed  in 
every  Avay  the  most  characteristic,  are  the  dull  pain,  a  frequent 
desire  to  make  water,  and  the  passage  of  a  large  quantity  of  muco- 
pus  or  pus  with  each  act  of  micturition.  The  urine,  on  stand- 
ing, deposits  a  thick,  glairy,  viscid  sediment,  in  which,  under  the 
microscope,  triple  phosphates  and  large  pus-corpuscles,  extremely 
regular  both  in  contents  and  in  shape,  may  be  detected. 

The  diagnosis  of  the  disease  in  males  is  easy.  The  only  affec- 
tion with  which  it  is  liable  to  be  confounded  is  abscess  of  the 
kidney.  In  females,  uterine  disorders  may  so  closely  simulate  it 
that  it  may  require  a  local  examination  to  tell  the  difference. 

But,  having  decided  the  case  to  be  one  of  chronic  cystitis,  it  is 
always  more  difficult  to  discover  its  exciting  cause.  We  have  to 
depend,  to  a  great  extent,  upon  the  history  of  the  malady;  its 
association  with  a  stone  can  be  determined  only  by  the  use  of  the 
sound. 

Abscess  of  the  Kidney. — This  dangerous  condition  is  the 
result  of  suppurative  inflammation  of  the  kidney,  or  of  abscesses 
forming  in  connection  with  pyaemia,  or  with  embolism.  The 
suppurative  inflammation  is  sometimes  traceable  to  an  acute  attack 
of  nephritis  brought  on  by  exposure  or  by  external  violence,  to 
retention  of  urine,  or  to  the  impaction  of  a  renal  calculus ;  but 
at  other  times  it  originates  without  any  assignable  cause,  and  in 
an  insidious  way.     The  association  of  suppurative  nephritis  with 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORfJANS.       745 

erysipelas  has  engaged  much  attention,  and  the  renal  affection  is 
even  thought  to  be  erysipelatous  in  its  origin.* 

When  the  disorganizing  jirocess  has  continued  for  some  time, 
and  the  abscesses  are  fairly  formed,  we  encounter  these  signs :  a 
fulness  on  one  side  of  the  spine  in  the  lumbar  region,  associated 
with  tenderness  on  deep  pressure  and  with  more  or  less  constant 
pain,  the  pain  and  tenderness  being  increased  by  lying  on  the 
affected  side  ;  fever  and  occasional  rigors ;  digestive  disturbances, 
and  the  presence  of  blood  and  pus  in  the  scanty  urine.  In  some 
cases  a  marked  tumor  is  found  in  the  loin,  extending  toward  the 
iliac  fossa.  If  the  abscess  burst  into  the  calices,  there  occurs, 
simultaneously  with  a  subsidence  of  the  tumor,  a  sudden  and 
copious  discharge  of  pus  with  the  urine,  or,  if  it  break  into  the 
intestine,  with  the  fsecal  evacuation. 

The  disease  almost  never  affects  more  than  one  kidney :  hence 
so-called  ursemic  symptoms  are  rarely  met  with,  since  the  healthy 
kidney  enlarges  and  becomes  capable  of  performing  a  double 
amount  of  work.  Ebstein  f  has,  however,  observed  that  chronic 
abscess  in  one  kidney  may  produce  amyloid  disease  of  the  other. 
The  disorder  gradually  leads  in  most  cases  to  a  fatal  issue,  from 
the  irritation,  the  vomiting,  the  diarrhoea,  the  wasting  discharge, 
and  the  protracted  hectic;  sometimes  paralysis  of  one  or  both  legs 
happens,  adding  greatly  to  the  distress.  There  is  a  possibility  of 
recovery,  if  the  patient  have  strength  enough  to  withstand  the 
purulent  drain  until  the  abscess  empties  itself.  It  may  do  this 
through  the  urinary  passages,  through  the  colon,  through  the 
lumbar  muscles,  through  the  diaphragm,  and  be  evacuated  by 
coughing,  and  the  cavity  of  the  abscess  then  cicatrizes ;  or  the 
abscess  may  burst  into  the  peritoneal  cavity  and  cause  rapid  death. 

The  diseases  for  which  the  malady  is  most  apt  to  be  mistaken 
— leaving  out  those  extremely  rare  cases  in  which  abscesses  from 
diseased  vertebrae  break  suddenly  into  the  urinary  tract  —  are 
chronic  cystitis,  perinephritis,  and  pyelitis.  From  cystitis  it  may 
be  distinguished  by  the  dissimilar  local  signs  and  the  different 
appearances  of  the  urine.  Thus,  in  the  affection  of  the  bladder 
the  quantity  of  pus  constantly  discharged  is  far  greater, — for  in 


*  Goodhart,  Guy's  Hospital  Reports,  3d  Series,  vol.  xix. 
f  Ziemssen's  Cyclopaedia. 


746  MEDICAL   DIAGNOSIS. 

abscess  of  the  kidney  there  are  times  when  bnt  little  or  no  })us  is 
voitled;  on  the  other  hand,  the  urine  of  the  vesical  disorder  is  less 
albuminous.  Yet  this  is  not  a  certain  guide,  for  we  may  have 
a  Bright's  kidney  associated  with  a  catarrh  of  the  bladder,  and 
thus  both  a  highly-purulent  and  a  highly-albuminous  urine  be 
produced.  In  this  case,  however,  a  diligent  search  with  the  micro- 
scope will  detect  casts  and  other  renal  products  in  the  sediment. 

Pennephritis  unconnected  ^vith  inflammation  of  the  kidney  is 
a  very  rare  disease.  When  primary,  it  may  result  from  exposure ; 
but  it  is  more  generally  due  to  contusion  or  strain.  I  saw  an  in- 
vStance  of  it  which  occurred  in  a  young  man  who,  returning  home 
from  a  long  walk,  strained  his  back  in  jumping  a  fence.  An  ab- 
scess gradually  formed,  giving  rise  to  a  slight  fulness  in  the  left 
lumbar  region,  and  severe  pain,  which  disappeared  as  matter  was 
discharged  through  the  integuments.  The  function  of  the  kidney 
was  not  affected.* 

But  an  external  opening  may  be  established  when  the  process 
of  inflammation  and  suppuration  has  begun  in  the  kidney  and 
thence  spread  to  the  loose  tissues  surrounding  it.  Under  these 
circumstances,  the  appearance  in  the  urine  of  pus  prior  to  its  dis- 
charge through  the  muscles  of  the  back  w^ould  be  the  only  certain 
means  by  which  we  could  judge  where  the  suppuration  had  pri- 
marily taken  place.  The  inflammation  may  also  travel  upward 
from  the  pelvic  viscera  or  from  the  head  of  the  colon ;  it  has 
not  unfrequently  been  noticed  after  irritation  of  the  testicles  and 
of  the  spermatic  cord.  Secondary  perinephritis  has  been  observed 
in  pyaemia,  and  after  typhoid  and  typhus  fevers  and  smallpox. 
The  disease  is  not  at  all  uncommon  in  childhood.t 


*  Trousseau,  in  his  Clinique  Medicale,  cites  several  instances  of  perlnephritic 
abscess.  See  also  Brit,  and  For.  Med.-Chir.  Rev.,  July,  1871 ;  Bovvditch,  Med. 
and  Surg.  Rep.  Boston  City  Hospital,  1st  Series,  and  Amer.  Jt)urn.  Med  Sci., 
April,  1871;  Duffin,  Med.  Times  and  Gaz.,  1872,  vol.  ii.  ;  Ebstein,  loc.  cit. ; 
Nieden,  Archiv  f.  Klin.  Med.,  1878;  John  B.  Roberts,  Amer.  Journ.  Med. 
Sci.,  April,  1883 ;  A.  3Iaodonald,  Edinb.  Med.  Journ.,  1884-85,  xxx. ;  T.  M. 
Woodscm,  Nashville  Journ.  Med.  and  Surg.,  1886,  N.  S.,  xxxvii. ;  W.  K. 
Sutherland,  New  Orleans  Med.  and  Surg.  Journ.,  1886-87,  N.  S.,  xiv. ;  Jo- 
hannes Lemkowski,  Greifswald,  1887,  F.  W.  Kunike,  31  pp.  8vo ;  A.  J. 
Banker,  Med.  Progress,  Louisville,  1887-88,  ii. ;  W.  H.  Heath,  Buffalo  Med. 
and  Surg.  Journ.,  1887-88,  xxvii.  ;  Follet,  Bull.  Med.,  Paris,  1888. 

f  Gibney,  Amer.  Journ.  of  Obst.,  reports  twenty-eight  cases,  April,  1876. 


THE   URINE,  AND    DISEASES   OF   THE   URINARY    ORGANS.      747 

The  prominent  symptom  in  perinephritis  is  pain,  which  at 
times  is  so  severe  as  to  confine  the  patient  to  bed  with  his  knees 
flexed,  with  a  sense  of  fulness  and  dragging  weight,  witli  ten- 
derness in  the  region  of  the  kidney,  and  with  lameness  owing  to 
the  interference  with  the  play  of  the  psoas  muscles.  The  urine 
is  generally  unaltered,  or  only  full  of  urates ;  the  bowels  may  be 
constipated,  owing  to  the  pressure  of  the  tumor  on  the  intestine. 
A  rounded,  doughy,  and  generally  indolent  swelling,  uninfluenced 
by  the  respiratory  movements,  is  usually  found  in  the  lumbar 
region  or  a  little  lower.  The  abscess  may  cause  pulmonary  or 
pleuritic  complications,  but  almost  never  gives  rise  to  jaundice. 
As  the  disease  advances,  severe  chills,  with  high  fever  and  copious 
night-sweats,  occur,  as  well  as  emaciation  and  marked  debility, 
and  the  thoracic  symptoms  may  mask  the  renal ;  fluctuation  may 
at  times  be  detected,  and,  before  the  abscess  breaks  externally,  a 
phlegmonous  appearance  of  the  skin  where  the  abscess  points  is 
not  unusual.     Great  relief  follows  the  discharge  of  the  pus. 

From  inflammation  of  the  psoas  muscle  we  distinguish  peri- 
nephritis by  the  absence  of  marked  sensitiveness  over  the  renal 
region  in  the  former  complaint,  and  by  flexion  of  the  thigh  in  it 
producing  pain. 

Pyelitis. — Inflammation  of  the  mucous  membrane  of  the 
pelvis  of  the  kidney  is  almost  never  idiopathic,  being  commonly 
caused  by  a  calculus  which  has  been  arrested  at  the  commence- 
ment of  the  ureter ;  or  by  a  retention  of  urine  from  an  obstacle 
in  the  ureter,  bladder,  or  urethra  ;  or  by  an  extension  upward  from 
the  bladder  of  an  inflammation.  Bright's  disease  and  diabetes 
are  not  unusually,  and  typhus  and  the  eruptive  fevers,  pyaemia, 
scurvy,  diphtheria,  carbuncle,  and  the  puerperal  state,  are  occa- 
sionally, complicated  with  some  degree  of  pyelitis.  Pyelitis  may 
be  also  catarrhal  or  rheumatic. 

The  symptoms  of  the  malady  are,  therefore,  in  part  those  pro- 
duced by  the  morbid  states  exciting  it,  especially  those  denoting  a 
calculus  lodged  in  the  kidney  or  arrested  in  its  transit  toward  the 
bladder ;  partly  those  directly  traceable  to  the  inflammation  of 
the  pelvis  and  infundibula.  The  manifestations  of  the  latter  dis- 
order are,  a  constant  dull  pain  in  the  loin,  felt  also  in  the  course 
of  the  ureter,  and  the  passage  of  pus  and  occasionally  of  small 
quantities  of  blood  with  the  urine  ;  in  cases  from  retention  and 


748  MEDICAL   DIAGNOSIS. 

decomposition  oi'  urine  thoro  are  ehills,  sweats,  vomiting,  head- 
ache, delirium,  and  a  low  lever.  In  most  cases  of  pyelitis  the 
nrfne  is  acid.  The  marketl  exception  is  in  the  instances  last 
mentioned,  where  it  is  apt  to  be  animoniacal  and  to  swarm  with 
bacteria.*  Bacteria  are  also  supposed  to  be  a  frequent  cause  of 
pyelitis,  as  well  as  of  abscess  of  the  kidney,  by  migrating  from  a 
diseasetl  bladder. 

The  most  ditiienlt  })oint  connected  with  the  recognition  of  pye- 
litis is  the  ascertaining  that  the  purulent  discharge  does  not  pro- 
ceed from  the  bladder.  And  there  is  no  positive  sign  to  guide 
us,  except  the  existence  in  the  urine  of  ej)ithelium  from  the  pelvis 
of  the  kidney,  distinguishable  by  their  oval  or  fusiform  shape, 
and  by  the  frequent  occurrence,  in  a  cell,  of  clearly-defined,  dark- 
colored,  round  granules,  and  of  two  nuclei.  But  this  epithelium 
may  not  always  be  found,  and  we  have  then  to  fall  back  upon  the 
history  of  the  case,  upon  the  attacks  of  renal  pain,  upon  the  luema- 
turia  caused  by  a  calculus,  and  upon  the  combination  of  signs  as 
pointing  more  to  one  disease  than  to  the  other.  In  some  cases 
there  is  a  perceptible  swelling  in  the  loin ;  at  times,  too,  owing  to 
coexisting  degeneration  of  the  cortex  of  the  kidney,  the  amount 
of  albumen  is  wholly  disproportionate  to  that  contained  in  pus, 
and  this  becx)mes  a  valuable  indication  of  the  affection  not  being 
vesical.  But  if  there  be  a  coincident  disease  of  the  bladder,  the 
differential  distinction  may  become  impossible.  Under  these  cir- 
cumstances, too,  the  acid  state  of  the  urine,  on  which  in  uncom- 
plicated cases  some  stress  may  be  laid,  is  not  apt  to  be  a  feature 
to  aid  us.  Pascallucci  t  has  brought  forward  a  sign  of  pyelitis 
which  he  regards  as  certain.  It  consists  in  taking  note  of  the 
manner  in  which  nitrate  of  urea  crystallizes  wheu  nitric  acid  is 
added  to  the  urine.  If  the  catarrh  be  limited  to  the  bladder,  the 
microscope  shows  the  crystals  arranged  in  the  ibrm  of  hexagonal 
rhomboidal  blades ;  in  pyelitis  the  blades  are  irregular  and  set 
at  angles,  and  some  of  them  are  in  the  shape  of  small  feathers. 

Supposing  the  point  settled,  and  the  vesical  origin  of  the  pus  dis- 
proved, the  diagnosis  is  limited  to  an  inflammation  of  the  ureter, 
to  an  abscess  in  the  substance  of  the  kidney,  and  to  pyelitis. 


*  Ebstein,  art.  "  Pyelitis,"  in  Ziemssen's  Cyclopaedia. 
f  II  Morgagni,  quoted  in  Lancet,  .June,  1873. 


THE    URINE,  AND    DISEASES    OF   THE    URINARY    ORGANS.       749 

Here  again  the  histoiy  of  the  case  comes  into  play.  Further- 
more, in  the  former  of  these  affections — a  very  rare  one,  unless 
associated  with  pyelitis — the  amount  of  pus  in  the  urine  is  very 
trifling ;  in  the  second,  too,  it  is  less  than  in  pyelitis,  except 
when  the  abscess  empties  itself.  The  pus  is  also,  as  already 
indicated,  not  constant,  alternately  appearing  in  and  disappearing 
from  the  urine;  there  is  usually  more  obvious  swelling,  although 
this  is  by  no  means  always  discernible  or  even  present  in  abscess, 
and  the  abscess  is  attended  with  much  greater  constitutional  dis- 
turbance. Still,  here  again  we  must  admit  that  the  disorders  are 
sometimes  very  obscure  and  difficult  to  distinguish,  and  it  may  be 
impossible  to  discriminate  between  them  should  the  morbid  states 
coexist,  or  a  typhoid  condition  and  ursemic  fever  be  induced  by 
the  retention  of  the  urine  and  its  decomposition. 

Catarrhal  or  rheumatic  jyyditis  is  generally  a  short  disease  which 
ends  favorably;  so  does  the  idiopathic  pyelitis  of  the  puerperal 
state,  which  rarely  lasts  more  than  from  five  to  eight  days.  The 
pyelitis  with  retention  and  decomposition  of  urine  is  a  much 
more  serious  complaint,  and,  although  it  usually  runs  a  rapid 
course,  not  having  a  duration  of  more  than  a  week  or  two,  it 
may  become  a  protracted  state.  Pyelitis  due  to  the  irritation  of 
calculi  is  apt  to  develop  into  a  chronic  condition. 

In  those  cases  of  pyelitis  in  which  there  is  a  very  decided  ob- 
struction to  the  flow  of  urine  through  the  ureter,  caused  by  a  cal- 
culus, clot  of  blood  or  viscid  pus,  or  other  debris,  the  discharge  of 
pus  is  suddenly  arrested  and  the  cavity  of  the  pelvis  dilates  greatly ; 
gradually  the  gland-tissue  is  compressed,  and  a  large  pus-contain- 
ing sac  is  formed,  giving  rise  to  a  condition  known  as  pyonephrosis, 
and  to  a  distinctly  limited  swelling  in  the  side.  Tumors  of  this 
kind  are  ordinarily  not  painful  to  the  touch,  are  sometimes  very 
indolent,  and  do  not  materially  affect  the  general  health,  certainly 
not,  as  a  rule,  nearly  as  much  as  might  be  supposed.  They  not 
unfrequently  subside  gradually  by  free  discharges  of  pus,  and  the 
patient  recovers.*  Sometimes  they  become  much  reduced,  and 
then  swell  up  again  from  time  to  time.  They  have  been  known 
to  occur  in  both  kidneys ;  but  this  is  of  great  rarity. 


*  See,  for  instance,  Cases  XLVIII.  and  L.  in  Todd's  Clinical  Lectures  on 
the  Urinary  Organs. 


750  MEDICAL   DIAGNOSIS. 

Pyonephrosis  cannot  be  distinguished  from  suppurative  nephritis 
and  ordinary  abscess  of  the  kidneij,  except  it  be  by  the  history. 
The  more  constant  and  hirger  discharge  of  pus  may  also  be  made 
a  point  of  diagnosis,  as  weW  as  the  obvious  variations  in  the  swell- 
ing and  the  slighter  constitutional  symptoms.  But  too  nuich 
stress  must  not  be  laid  on  these  points ;  and  the  fact  should  not 
be  overlooked  that  abscess  of  the  kidney  may  be  latent,  be  present 
almost  without  fever,  or  with  very  obscure  manifestations  of  })ain, 
irregular  attacks  of  fever,  and  vomiting,  coming  on  at  intervals 
for  months  or  years. 

When  the  changes  resulting  from  an  impediment  to  the  flow  of 
urine  are  unassociated  with  suppuration  of  the  mucous  membrane 
of  the  iK'lvis  of  the  kidney,  although  the  pelvis  dilates  extraor- 
dinarily and  the  kidney-tissue  in  time  disappears,  we  have  the 
condition  designated  by  Raver  as  hydronephros-is.  It  is  often  due 
to  retroflexion  or  to  cancer  of  the  womb,  to  morbid  growths  or  to 
abscess  of  the  bladder,  or  to  congenital  malformation  of  the  ureter. 
Sometimes  it  is  double.  The  swelling  to  which  it  gives  rise  may 
subside  simultaneously  with  a  sudden  and  copious  discharge  of 
urine.  When  this  symptom  is  absent,  the  diagnosis  must  be  based 
on  the  existence  of  a  fluctuating  renal  tumor  and  on  the  absence  of 
signs  of  suppuration.*  It  may  lead  to  temporary,  but  entire,  sup- 
pression of  urine.  Accurate  percussion  enables  us  to  distinguish 
hydronephrosis  from  ascites ;  in  the  former  the  dulness  is  generally 
one-sided,  and  it  is  uninfluenced  by  change  of  position.  Ovarian 
cysts  are  more  difficult  to  discriminate.  Careful  examinations  by 
the  rectum  and  by  the  vagina,  and  an  investigation  of  the  fluid 
after  an  exploratory  puncture,  are  alone  of  value  ;  and  even  they 
may  mislead.  Urinary  constituents,  for  instance,  have  been  found 
to  be  absent  in  rare  cases  of  hydronephrosis. 

Hydatid  tumor  of  the  kidney  is  of  comparatively  rare  occur- 
rence, and  is  very  apt  to  be  confounded  with  hydronephrosis. 
When  the  urine  contains  no  hydatid  vesicles  or  their  debris  and 
the  hydatid  fremitus  is  absent,  the  diagnosis  is  extremely  difficult, 
and  must  rest  chiefly  on  the  history  of  the  case. 

Ordinary  renal  cysts,  when  large  enough  to  occasion  a  tumor, 
cannot  be  distinguished  from  hydronephrosis  save  by  the  history, 


*  See  Schroeder,  Diseases  of  the  Female  Sexual  Organs,  p.  385. 


THE    URINEj  AND    DISEASES    OF    THE    URINARY    ORGANS.       751 

and  by  the  albuminous  and  bloody  urine  which  the  cysts  give  rise 
to,  while  in  hydronephrosis  the  urine  presents  nothing  peculiar, 
or  occasionally,  only  small  amounts  of  pus. 

Pyelitis  may  be  connected  with  fibrinous  clots  due  to  repeated 
hemorrhages  from  multiple  aneurisms  of  the  renal  artery.  We 
may  suspect  this  condition  if  the  other  more  usual  causes  of 
pyelitis  seem  to  be  absent,  and  if  the  affection  happen  in  an  old 
person  having  repeated  attacks  of  hsematuria  and  atheromatous 
arteries.* 


Disorders  in  which  a  very  large  Amount  of  Urine  is  discharged, 

Diabetes. — In  diabetes  mellitus,  or  glycosuria,  the  urine  is  of 
pale  color  and  of  high  specific  gravity,  ranging  generally  from 
1030  to  1050.  The  quantity  passed  is  enormous :  seventy  pints 
and  upward  have  been  known  to  be  discharged  daily.  The  urea 
is  generally  increased ;  so  are  the  sulphates  and  the  chlorides,  and 
the  earthy  phosphates,  while  the  alkaline  phosphates  vary  greatly 
with  the  food,  and  uric  acid  is  probably  diminished.  In  a  small 
proportion  of  cases  the  flow  of  urine  is  not  increased. 

The  symptoms  attending  the  drain  of  fluid  from  the  system  are 
great  thirst,  constipation,  and  generally  a  dry,  harsh  skin,  a  red 
tongue,  and  a  feeling  of  constant ,  emptiness  and  of  hunger.  To 
these  are  added  a  steadily-progressing  waste  of  the  body,  mus- 
cular feebleness,  chills,  a  somewhat  hurried  breathing,  a  peculiar 
mawkish  odor  of  the  breath,  peevishness  of  temper,  a  tendency  to 
eczema  and  to  boils  and  carbuncles,  and  in  women  pruritus  of  the 
vulva.  Cataract  and  other  kinds  of  defective  vision  are  not  in- 
frequent. The  knee-jerk  is  generally  absent.  Galezowskif  has 
described  a  peculiar  form  of  retinitis  in  diabetes ;  retinal  hemor- 
rhage, and  palsies  of  the  muscles  of  the  eyeball,  have  also  been 
noticed.  Attention  has  been  directed  to  diabetic  hypermetropia, 
and  with  the  change  of  refraction  a  quantity  of  sugar  in  the  urine 
is  observed. J  Defects  in  accommodation  are  common.  Diabetic 
endocarditis  also  happens,  and  is  more  frequent  in  women  than  in 

*  OHivier,  Archives  de  Physiologie,  1873. 

t  Compte-Eendu  du  Congres  Ophtli.  de  Paris,  1862. 

X  Landolt,  El  Siglo  Medico,  quoted  in  Lancet,  April,  1880. 


752  MEDICAL    DIAGNOSIS. 

men  ;*  and  neurites  and  neuralgias  and  periostitis f  and  arthritic 
disorders;}:  may  liave  tiieir  origin  in  diabetes.  Double  seiatioa  is 
often  of  diabetic  source.  There  is  Ircquently  a  connection  to  be 
traced  between  gout  and  diabetes. 

Diabetes  is  a  very  fatal  disease ;  yet  it  is  imjiossiblc  to  foretell 
its  exact  mode  of  termination.  Some  are  cut  oif  rather  suddenly ; 
others  drag  out  a  long  existence,  and  die  worn  out  and  dropsical, 
or  of  cirrhosis  of  the  liver,  or  of  superadded  phthisis.  For  some 
days,  or  even  for  weeks,  before  death,  the  sugar  may  disappear 
from  the  urine.§  Diabetic  gangrene  is  also  a  mode,  though  not 
a  frc(|uent  one,  of  termination  of  the  disease.]! 

When  the  disease  ends  suddenly,  it  is  apt  to  do  so  by  so-called 
diabetic  coma.  The  comatose  condition  is  prone  to  be  preceded 
by  vomiting  and  abdominal  pain,  rapid  pulse,  great  anxiety  and 
restlessness,  labored  breathing,  depressed  body-heat,  headache, 
and  drowsiness.  These  symptoms  are  attributed  to  the  poisoning 
of  the  body  by  the  development  of  acetone,  a  derivative  of  acetic 
acid,  in  the  blood,  and  it  is  asserted  that  acetone  can  be  found  in 
the  urine,  and  may  be  readily  detected  on  the  breath  by  its  odor 
resembling  that  of  chloroform.  The  evidence,  however,  of  the 
decomposition  of  the  sugar  into  acetone,  and  of  the  consequent 
nervous  symptoms  called  diabetic  coma,  is  still  not  conclusive. 
At  all  events,  it  is  certain  that  there  may  be  diabetic  coma  with- 
out acetonuria,  and  acetonuria  without  coma  and  even  without 
diabetes. 

Whence  comes  the  sugar  ?  Is  it  from  the  food  ?  the  blood  ?  the 
stomach  ?  the  liver  ?  These  are  questions  that  cannot  be  satisfac- 
torily answered.  Since  Bernard's  discovery  of  the  sugar-forming 
properties  of  the  liver,  saccharine  urine  is  thought  to  proceed  from 
an  inordinate  formation  in  this  viscus  of  sugar,  which  is  not  fully 
destroyed  in  the  lungs  and  is  excreted  by  the  kidneys.     On  the 


*  Lecorche,  Arch.  Gen.  de  Med.,  .Tune,  1882;  Bulletin  de  lAead.  de  Med., 
1880. 

t  Arch.  Gen.  de  Med.,  Feb.  1882,  and  Amer.  Journ.  Med.  Sci.,  April,  1882. 

jDycc  Duckworth,  St.  Barth.  Hosp.  Rep.,  vol.  xviii.,  1882. 

^  In  a  case  for  a  long  time  under  my  charge,  in  which  the  diabetes  lasted 
for  several  years,  sugar  entirely  disappeared  from  the  urine  as  the  signs  of 
phthisis  became  fully  developed,  and  for  several  months  before  death. 

II  See  cases  collected  by  Hunt,  Transact.  Phila.  Co.  Med.  Soc,  Nov.  1888. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       753 

whole,  this  view  has  been  sustained  ;  hut  it  is  impossible  to  apply 
it  clinically  as  an  exclusive  theory.  We  find  sugar  in  some  in- 
stances of  gastric  malassimilation,  yet  oftener  in  liver  affections, 
especially  in  cirrhosis.  That  the  sugar  is  not  derived  from  the 
sugar  in  food  is  certain  ;  for  patients  kept  even  on  the  most  rigor- 
ous meat  diet  still  pass  sugar.  In  some  cases  diabetes  has  been 
observed  to  be  associated  with  paralysis  of  the  tongue,  palate,  and 
vocal  cord,  and  other  signs  of  disease  in  the  floor  of  tlie  foiu'th 
ventricle,  or  of  tumors  pressing  there;  or  it  has  been  noticed  after 
fractures  of  the  skull  involving  the  base.  Dickinson  has  adduced 
much  evidence  of  the  frequent  connection  of  diabetes  with  altera- 
tions of  the  nervous  system.*  That  there  is  a  diabetes  of  nervous 
origin  can,  indeed,  not  be  doubted.  Again,  diabetes  in  a  number 
of  cases  has  been  found  to  be  linked  to  a  lesion  of  the  pancreas. 
It  also  often  follows  mental  emotion.  In  some  instances  it  is 
malarial,  in  others  hereditary. 

Starchy  and  saccharine  substances  increase  the  quantity  of  dia- 
betic sugar.  Nay,  they  may  be  the  cause  of  a  little  sugar  ap- 
pearing in  the  urine  of  healthy  persons.  Yet  those  in  whom  a 
saccharine  state  of  the  urine  is  readily  induced  are  in  great  danger 
of  becomino;  diabetic.  If  we  are  in  doubt  whether  we  are  dealino- 
with  a  case  of  diabetes,  we  may  follow  Seegen's  advice  and  let  the 
patient  eat  heartily  of  saccharine  and  sugar-forming  substances, 
and  examine  the  urine  three  hours  after  the  meal ;  if  no  sugar 
then  be  found  in  the  urine,  diabetes  may  be  excluded. 

In  the  aged,  sugar  may  be  present  in  the  urine  without  being 
attended  with  distressing  symptoms.  It  is  in  such  cases  that  we 
are  most  apt  to  meet  with  the  intermitting  diabetes  to  which 
attention  has  been  called  by  Bence  Jones.f  When  the  abnormal 
ingredient  thus  disappears  from  the  urine,  it  is  replaced  by  uric 
acid  and  by  oxalates.  There  is  still  another  form  of  intermitting 
glycosuria.  Sugar  is  sometimes — Burdel  |  says  uniformly — found 
in  the  urine  during  the  paroxysms  of  intermittent  fev^er ;  but  it 
vanishes  during  the  intervals. 

Sugar  is  also  found  in  the  urine  in  small  quantities  after  in- 


*  Medico-Chirurgical  Transactions,  1870,  and  Diseases  of  the  Kidney,  1875. 
f  Medico-Chirurgical  Transactions,  vol.  xxxviii. 
I  L'Union  Medicale,  No.  139,  1859. 

48 


754  MEDICAT.    DIAGNOSIS. 

lulling-  chloroform  or  taking  chloral.  Among  the  inpanc,  sngar 
may  be  present  in  the  nrinc  \vithont  there  being  other  symptoms 
of  diabetes,  and  without  grave  significance.*  Indeed,  this  ap- 
pearance of  sugar  in  the  urine  from  passing  causes  or  without 
other  marked  symptoms  has  given  rise  to  the  distinction  made  by 
some  between  ghjcosnria  and  diabetes,  restricting  the  latter  term 
to  persistent  saccharine  urine  with  decided  symptoms  and  most 
likclv  with  a  lesion. f  The  passing  glycosuria  gets  well  ;  true 
diabetes  is  not  a  curable  affection. 

In  some  instances  we  have  diabetes  vith  coexisting  albuminuria, 
and  even  with  other  evidence  of  Bright's  disease.  In  the  majority 
of  such  instances  the  degeneration  of  the  kidneys  has  happened 
subsecpiently  to  the  diabetes,  and  in  its  more  advanced  stages;  but 
I  have  met  with  cases  in  which  Bright's  disease  has  preceded  the 
diabetes.  Amyloid  kidney  has  also  been  noticed  in  connection 
Avitli  diabetes. 

Chronic  Diuresis. — This  disease  is  otherwise  known  as  poly- 
uria or  diabetes  insipidus.  It  is  characterized  by  the  habitual 
discharge  of  a  very  large  quantity  of  urine  of  low  specific  gravity, 
containing  an  excess  of  water,  but  no  sugar.  The  general  symp- 
toms are  much  the  same  as  those  of  diabetes ;  the  thirst  is  gener- 
ally extreme,  and  it  may  happen  that  more  water  is  passed  than 
is  drunk.  j\Iost  cases  recover  under  treatment,  except  when 
dependent  upon  irremediable  lesion.  They  sometimes  die  of  sup- 
pression of  urine.;}; 

The  cause  of  this  singular  malady  is  obscure.  We  meet  with 
polyuria  after  cerebro-spinal  fever,  or  in  connection  with  tumors 
of  the  brain,  or  with  disease  of  the  medulla  oblongata  or  of  part 
of  the  floor  of  the  fourth  ventricle,  or  with  tumors  compressing 
the  abdominal  ganglia.  Lancereaux  tells  us  that  the  disorder  is 
not  uncommon  in  syphilitic  affections  of  the  nervous  centres  ;§ 
and  Bartholow's  experience  is  that  syphiloma  of  the  brain  is  its 
most  usual  cause.  I  have  repeatedly  encountered  the  malady 
after  injuries  to  the  head,||  after  sun-stroke,  or  in  persons  broken 

*  Lailler,  quoted  in  ,J(jurnal  of  Mental  Science,  Maj-,  1871. 

t  Lancereaux,  Bulletin  de  I'Acad.  de  Med.,  Nov.  1877. 

%  Case  under  my  charge  at  the  Philadelphia  Hospital. 

^  Sydenham  Society's  Translation,  p.  76. 

II  Transactions  of  the  College  of  Physicians  of  Philad^'lphia,  1875. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       755 

down  with  malaria.  At  times  it  is  seen  in  instances  simply  of 
great  nervous  depression  without  organic  disease.  It  is,  indeed, 
mostly  connected  with  some  abnormal  state  of  the  nervous  system. 
It  has  been  stated  to  coexist  with  marked  excess  of  phosphates, 
and  to  be  a  phosphaturia.  But  Senator  has  shown  that  kreatinin 
too  is  excreted  in  diabetes  insipidus  in  increased  quantity;  indeed, 
in  the  whole  amount  of  urine  passed  most  or  all  of  the  solid 
ingredients  are  found  in  rather  increased  quantity.* 

We  must  take  care  not  to  confound  cases  of  chronic  polyuria 
Avith  true  diabetes.  They  differ  by  the  low  specific  gravity  of  the 
urine,  and  the  utter  absence  of  a  saccharine  ingredient. f  Some- 
times a  state  of  diuresis  is  found  to  exist  temporarily  during  the 
removal  of  dropsical  effusions,  or  when  the  action  of  the  skin  is 
insufficient.  We  also  meet  with  apparent  cases  of  diuresis  in 
hysterical  women  and  in  persons  who  suffer  from  incontinence 
of  urine,  whether  due  to  an  external  injury,  or  dependent  upon 
simple  irritability,  or  upon  inflammation  or  paralysis  of  the 
bladder.  In  all  such,  however,  we  can  establish  the  diagnosis  by 
laying  stress  on  the  history  of  the  patient,  and  by  measuring  the 
amount  of  urine  passed  in  the  twenty-four  hours, — which  amount 
may  be  large,  but  is  not  inordinate.  In  hysteria  it  may  be  tem- 
porarily very  large  after  a  paroxysm,  but  is  not  persistently  so. 
In  some  instances  diabetes  mellitus  alternates  with  diabetes  in- 
sipidus. The  discovery  of  an  hydrsemic  centre  in  the  cerebellum 
by  Eckhard,  as  well  as  the  well-known  points  at  the  floor  of  the 
fourth  ventricle,  which,  according  to  the  exact  seat  of  puncture, 
produce  increased  flow  of  urine  with  sugar  or  without  sugar,  gives 
us  the  clue  in  which  direction  to  look  for  the  explanation  of 
such  cases.  The  large  flow  of  urine  we  sometimes  meet  with  in 
contracted  kidney  is  told  from  hydruria  by  the  presence  of  albumen 
and  tube-casts  and  the  other  signs  of  kidney  degeneration.  An 
excessive  flow  of  urine  may  happen  in  hydrone'plirosis.  But  the 
antecedent  history,  the  previous  existence,  as  a  rule,  of  a  fluctu- 
ating tumor,  and  the  character  of  the   urine,  either  normal   or 


*  Blau,  in  a  comprehensive  article  in  Schmidt's  .Jahrbiicher,  No.  7,  1877. 

t  See,  on  the  examination  of  the  urine,  the  cases  collected  by  Parkes,  On 
the  Composition  of  the  Urine,  London,  1860;  Dickinson,  Diseases  of  the  Kid- 
ney, 1875  ;  and  Grancher,  Gazette  des  Hopitaux, 


756  MEDICAL   DIAGNOSIS. 

containing-  at  times  traces  of  albumen  or  of  blood,  will  throw 
light  on  the  character  of  the  malady. 

Disorders  in  which  little  or  no  Urine  is  Discharged. 

Suppression  of  Urine. — Suppression  of  urine,  unconnected 
with  degeneration  of  tiie  kidney,  is  a  rare  disorder.  Yet  it  may 
occur  in  previously  healthy  persons,  or  in  the  course  of  fevers  of 
low  type,  and  probably  associated  with  no  other  morbid  state  than 
congestion  of  the  kidneys.  It  is  occasionally  met  with  as  one  of 
the  freaks  of  hysteria,  or  is  caused  seemingly  by  the  irritation 
reflected  to  a  healthy  kidney  from  a  diseased  bladder. 

The  symptoms  it  occasions,  independently  of  the  absence  of  the 
discharge  of  urine,  are  drowsiness,  nausea,  vomiting,  coma,  some- 
times convulsions ;  in  one  word,  the  symptoms  of  urseraic  poison- 
ing. Irrespective  of  these,  as  Bourneville*  has  shown,  the  pulse 
and  temperature  both  sink  in  ursemia,  and  the  temperature  remains 
low  even  if  there  be  coexisting  internal  inflammations ;  and  the 
formidable  complaint  may  give  rise  to  marked  urinous  smell  of 
the  perspiration  and  of  the  breath,  and  to  exceeding  and  very 
general  cutaneous  hyperaesthesia.t  As  regards  the  temperature, 
however,  it  must  be  remembered,  as  already  stated,  that  it  may 
be  above  the  norm. 

Concerning  the  exact  cause  of  the  suppression,  we  are  often 
kept  in  the  dark  until  the  termination  of  the  malady  ;  for,  unless 
we  are  familiar  with  the  patient's  antecedent  symptoms,  we  are 
unable  to  determine,  in  the  absence  of  the  urinary  secretion, 
whether  or  not  a  disease  of  the  kidney  lies  at  the  origin  of  the 
mischief.     The  affection  is  very  serious. 

Oppolzer  tells  us  that  we  may  diagnosticate  thrombosis  of  the 
renal.vdn  if  we  have  diminution  of  the  secretion  of  urine  and  its 
final  suppression  preceded  by  blood,  albumen,  and  casts  in  the 

*  Gazette  Medicale  de  Paris,  1872. 

f  This  was  the  most  obvious  symptom  in  a  case  under  my  care  in  1864  at 
the  Phihidelphia  Hospital,  in  which  no  urine  was  secreted  for  many  da3'S,  the 
catheter  being  repeatedly  introduced  into  the  bladder.  The  patient  recovered. 
She  had,  previous  and  subsequent  to  the  attack,  vesical  catarrh.  In  a  case 
reported  by  Fuller,  St.  George's  Hospital  Reports,  vol.  v.,  the  difficulty  existed 
for  eight  days  without  occasioning  convulsions.  It  was  the  same  in  a  case  of 
mine  that  lasted  eleven  days  and  got  well. 


THE   URINE,  AND    DISEASES   OF   THE   URINARY   ORGANS.      757 

urine.     If  there  be  a  history  of  severe  injury  to  the  kidney,  these 
symptoms  have  a  much  more  positive  meaning. 

Retention  of  Urine. — The  urine  retained  in  the  bladder 
distends  the  viscus  and  forms  a  swelling  in  the  hypogastrium, 
discoverable  both  by  palpation  and  by  percussion.  The  urine  is 
generally  not  wholly  kept  back,  for  a  slight  discharge  every  now 
and  then  takes  place,  or  there  is  a  constant  dribbling, — a  matter 
which  in  itself  should,  suggest  the  introduction  of  a  catheter. 

Retention  of  urine,  if  soon  recognized,  is  not  in  itself  a  dan- 
gerous complaint,  as  it  can  be  at  once  relieved  by  the  passage  of 
a  catheter ;  but  if  the  ailment  escape  observation,  or  be  ineffi- 
ciently dealt  with,  the  bladder  may  burst, — although  Sir  Henry 
Thompson  tells  us  that  this  is  a  circumstance  of  exceeding  rarity, 
— or  the  patient  dies  from  the  absorption  of  the  noxious  urinary 
ingredients. 

The  causes  which  lead  to  retention  are  various ;  promment 
among  them,  at  least  in  a  medical  point  of  view,  is  paralysis  of 
the  bladder,  especially  that  form  of  paralysis  which  occurs  in  low 
fevers  ;  retention  is  also  one  of  the  symptoms  of  paraplegia  ;  then 
inflammatory  swelling  of  the  neck  of  the  bladder,  organic  stric- 
ture, or  enlarged  prostate  may  give  rise  to  it ;  again,  retention  or 
incontinence  may  be  due  to  hysteria. 

The  disorder  is  readily  detected.  It  may  be  discriminated  from 
suppression  of  urine  by  the  existence  of  the  hypogastric  tumor, 
and  by  the  introduction  of  a  catheter, — a  means  which,  in  cases 
of  doubt,  ought  never  to  be  neglected.  Sometimes  the  abdominal 
swellino;  is  so  great  as  to  lead  to  the  belief  of  the  existence  of 
dropsy  ;  and  the  error  is  fostered  by  learning  that  the  patient  has 
been  passing  his  water,  and  has  a  constant  desire  to  discharge  it, 
or  by  seeing  that  it  dribbles  from  him.* 

The  retention  from  paralysis  is  distinguished  from  that  due  to 

other  causes,  as  obstruction,  by  observing  that  the  catheter  enters 

readily,  and  that    the  urine  flows  out    in  a  continuous   stream, 

.  increasing  and  lessening  with  the  respiratory  movements,  but  does 

not  come  out  in  jets. 

*'Iii  a  case  reported  by  Schneider,  and  quoted  in  Brit,  and  For.  Med.-Chir. 
Rev.,  April,  1864,  ui-ine  was  passed;  yet  when,  owing  to  the  peculiar  shape 
of  the  tumefaction,  a  catheter  was  introduced,  fourteen  pints  of  urine,  and 
subsequently  eight  more,  were  removed. 


CHAPTEE  VIII. 

DROPSY. 

An  abnormal  collection  of  watery  fluid  in  the  areolar  tissue 
or  in  the  serous  cavities  of  tlie  body  constitutes  dropsy.  Now, 
dropsy  is  but  a  symptom,  and  as  such  we  have  already  examined 
into  it  as  associated  with  various  disorders ;  but,  though  only  a 
symjitom,  it  is  one  so  obvious,  and  comprises  so  often  appa- 
rently the  whole  complaint,  that  it  will  serve  a  useful  purpose  to 
investigate  connectedly  the  clinical  meaning  of  its  typical  forms. 

Dropsy,  according  to  its  Seat  and  Extent. 

Dropsies  may  be  external,  or  be  confined  to  internal  parts. 
To  the  latter  variety  belong  hydrothorax,  hydrocephalus,  and 
ascites, — aifections  elsewhere  described,  which  we  shall  consider 
here  only  so  far  as  they  may  form  part  of  a  general  dropsy. 

External  dropsies  are  illustrated  by  anasarca  and  oedema:  the 
first,  a  universal  accumulation  of  serous  fluid  in  the  areolar  text- 
ures ;  the  second,  a  localized  collection  in  the  same  structures, 
diifering,  therefore,  in  nothing  but  extent.  Both,  as  ordinarily 
met  with,  exhibit  painless  swelling  of  the  surface,  devoid  of  red- 
ness ;  a  skin  often  stretched  and  shining,  pitting  upon  pressure, 
and  retaining  for  some  time  the  mark  of  the  finger ;  and  in  both, 
the  tumid  part,  if  punctured,  allows  a  watery  fluid  to  run  out. 
(Edema  is  most  commonly  perceived  around  the  ankles ;  the 
tumefaction  of  anasarca  is  found  generally  not  only  in  the  lower 
extremities,  but  also  in  the  arras  and  in  the  face. 

Anasarca  is  usually  dependent  uj^on  disease  of  the  kidneys,  or 
of  the  heart.  The  swelling  rarely  shows  itself  at  all  parts  of  the 
body  at  once ;  it  ordinarily  begins  at  the  feet  and  ankles  in  dis- 
eases of  the  heart,  in  the  face  in  diseases  of  the  kidney.  It  is 
greatest  Avhere  the  areolar  tissue  is  loosest. 
758 


DROPSY.  .  75f) 

(Edema  may  bo  duo  to  tho  samo  causes.  Yet  a  limited  collec- 
tion of  fluid  is  often  the  consequence  of  a  purely  local  difficulty 
unconnected  with  visceral  disease,  but  of  a  character  interfering 
with  the  venous  circulation.  Thus,  the  compression  or  oblitera- 
tion of  a  large  vein  occasions  oedema  below  the  point  of  the  dLs- 
order.  We  see  oedema  happening  if  a  bandage  be  applied  too 
tightly,  or  if  swollen  glands  press  upon  the  main  vein  of  a  limb. 
We  also  meet  with  it  in  the  adhesive  form  of  venous  inflamma- 
tion, and  in  milk-leg,  or  'phlegmasia  dolens, — a  condition  observed 
in  puerperal  women,  or  as  a  sequel  of  typhoid  fever,  in  which  the 
whole  of  one  lower  extremity  becomes  oedematous,  in  consequence 
of  the  blocking  up  of  the  femoral  vein  by  a  coagulum.  In  all  of 
these  forms  the  oedema  is  one-sided;  and,  the  cause  being  external 
to  the  thoracic  or  the  abdominal  cavity,  there  is  little  difficulty  in 
its  recognition.  A  circumscribed  oedema  also  accompanies  erysip- 
elatous inflammations  of  the  skin  or  subjacent  tissues;  so,  too,  do 
Ave  find  oedema  confined  to  a  limb  the  general  nutrition  of  which 
has  been  lowered  by  paralysis. 

When  the  dropsical  effusion  is  dependent  upon  a  tumor  seated 
in  an  internal  cavity  and  interfering  with  the  passage  of  the  blood, 
it  may  be  very  local  and  one-sided,  as  we  sometimes  find  in  con- 
nection with  abdominal  cancer ;  but  it  is  most  apt  to  be  found  on 
both  sides  of  a  portion  of  the  body,  although  more  particularly 
marked  on  one  side.  The  oedematous  extremities  exhibit  usually 
also  marked  enlargement  of  the  veins. 

Another  source  of  a  double-sided  oedema  is  ansemia.  This 
form  of  dropsy  is  often  seen  without  there  being  any  disease  of  an 
internal  organ.  The  watery  state  of  the  blood  is  highly  favorable 
to  the  transudation  of  the  serum,  and  this  collects  first  about  the 
ankles,  and  subsequently  in  other  parts  of  the  body.  The  ab- 
sence of  any  discoverable  organic  affection,  the  pallid  countenance, 
the  pearly  whiteness  of  the  conjunctiva,  and  the  venous  murmurs 
in  the  neck,  are  very  significant. 

A  dropsical  effusion  in  part  of  similar  origin,  but  much  more 
often  connected  with  internal  dropsy,  especially  with  ascites,  is 
the  dropsy  we  observe  in  those  broken  down  by  malarial  poiso7i- 
ing.  The  state  of  the  liver  and  spleeu,  added  to  the  condition  of 
the  blood,  determines  the  greater  extent  of  the  effusion. 


760  MEDICAL    DIAGNOSIS. 


Dropsy,  according  to  its  Causation, 

Having  viewed  anasarca  and  oedema  as  in  the  main  uncom- 
bined  with  internal  dropsies,  and  as  forming  the  sole  signs  of  the 
dropsical  complaint,  let  us  now  look  at  them  Avhen  associated  with 
effusions  of  serum  elsewhere.  The  same  remarks  will  also  apply 
to  hydrothorax  and  to  ascites,  the  meaning  of  which,  when  oc- 
curring alone,  we  have  inquired  into,  but  which  we  shall  here 
consider  in  their  relations  to  general  dropsy,  or  that  form  of  the 
disorder  in  which  anasarca  or  oedema  coexists  with  dropsy  of  one 
or  of  several  of  the  large  serous  cavities. 

First,  let  us  examine  into  the  causes  of  general  dropsy.  The 
most  common  are  a  disease  of  the  heart,  of  the  kidneys,  or  of 
the  liver ;  so  common,  in  truth,  that  in  every  case  of  dropsy  we 
must  always  examine  these  organs  carefully.  According  as  the 
dropsical  accumulation  originates  in  a  morbid  state  of  these  vis- 
cera, it  is  called  cardiac,  or  renal,  or  hepatic. 

Cardiac  dropsy  arises  in  consequence  of  the  deranged  or  en- 
feebled circulation  produced  by  a  disease  of  the  M'^alls  and  cavities 
of  the  heart,  associated  or  not  with  a  valvular  lesion.  The  dropsy 
begins  in  the  feet  and  ankles,  being  much  influenced  by  position, 
and  gradually  extends  upward ;  but  it  is  rarely  very  obvious  in 
the  face  or  upper  extremities.  The  thighs  and  scrotum  are  some- 
times greatly  swollen,  and  there  is  a  watery  effusion  into  the 
pleural  cavities  or  into  the  pulmonary  parenchyma. 

Renal  dropsy  is  usually  much  more  general  than  cardiac  dropsy. 
It  does  not,  like  this,  begin  in  the  most  dependent  parts,  but  is 
oflen  first  noticed  in  the  face  and  eyelids.  There  is  hardly  a  space 
in  the  body  where,  as  the  complaint  progresses,  fluid  may  not 
accumulate.  The  proof  that  the  dropsy  is  renal  is  furnished  by 
the  presence  of  albumen  and  casts  in  the  urine. 

Occasionally  the  dropsy  is  owing  to  an  affection  both  of  the 
kidney  and  of  the  heart ;  and  the  inquiry  may  arise,  which  of 
the  organs  was  primarily  disturbed  and  gave  rise  to  the  dropsy  ? 
The  kidney  disorder  generally  precedes  the  heart  disorder.  Should 
it  be  of  importance,  in  an  individual  case,  to  determine  which  has 
occurred  first,  we  may  be  enabled  to  arrive  at  a  conclusion  by 
a  close  examination  of  the  history  of  the  case  :  did  the  patient 


DROPSY.  761 

suffer  from  palpitation  and  shortness  of  breath  prior  to  or  coincident 
with  the  anasarcous  condition,  and  has  he  ever  had  rheumatic 
fever?  or  did  he  have  an  attack  of  acute  dropsy  before  the  per- 
sistent swelling  of  the  feet  or  of  the  face  occurred  ?  If  this  have 
happened,  there  is  a  strong  probability  of  the  renal  disease  having 
been  antecedent  to  the  cardiac  malady. 

Hepatic  dropsy  may,  like  the  preceding  forms,  be  more  or  less 
general  ;  but  it  is  very  rarely  so,  unless  it  be  of  long  standing,  or 
unless  there  be  coexisting  disease  of  the  heart  or  of  the  kidneys. 
The  most  usual  kind  of  dropsy  depending  upon  an  affection  of 
the  liver  is  abdominal  dropsy,  and  this  is  so  well  understood  that 
ascites  is  frequently  looked  upon  as  constituting  a  proof  of  hepatic 
disorder.  But  it  is  a  mistake  so  to  regard  it ;  for  ascites  may  also 
be  produced  by  peritoneal  tumors  or  inflammation,  by  enlargement 
of  the  spleen  or  of  the  pancreas,  or  by  the  pressure  of  diseased 
glands, — in  fact,  by  any  lesion  which  occasions  a  decided  impedi- 
ment to  the  portal  circulation. 

Again,  it  is  possible,  though  it  is  not  a  cause  which  acts  often, 
that  mere  irritation  of  the  areolar  tissue  will  occasion  more  or  less 
general  dropsy.  This  was  a  favorite  doctrine  of  the  older  phy- 
sicians ;  and  H.  C.  Wood  thus  explains  the  dropsy  of  arsenical 
poisoning.*  Another  cause  of  general  dropsy,  especially  of  ana- 
sarca, is  peripheral  multiple  neuritis.  I  have  seen  this  in  obscure 
cases,  in  which  the  electric  reactions,  the  absence  of  the  knee-jerk, 
the  altered  sensation,  made  the  diagnosis  clear.f  Perhaps  this  is 
the  cause  of  the  dropsy  in  Beriberi, — an  affection  with  anasarca 
which  leaves  marked  susceptibility  to  the  malady  for  several  suc- 
cessive summers.  I 

Besides  these  sources  of  general  dropsy,  we  may  find  deteriora- 
tion of  the  blood,  with,  perhaps,  a  simply  enfeebled  condition  of 
the  heart,  giving  rise  to  it.  But  such  a  state  is  much  more  likely 
to  occasion  oedema,  or,  in  some  instances,  anasarca,  than  general 
dropsical  effusions ;  and  it  is  thus  that,  while  the  former  phe- 
nomena are  not  uncommon  in  exhausting  diseases  or  in  marked 
impoverishment  of  the  blood,  the  latter  are  rarely  met  with  unless 
there  be  at  the  same  time  some  cardiac  or  renal  complaint. 

*  Amer.  Journ.  Med.  Sci.,  July,  1871. 

f  As  in  a  case  seen  with  Dr.  Lewis  Brinton. 

X  Simmons,  Beriberi,  or  tlie  "  Kakke"  of  Japan,  Slianghai,  1880. 


7G2  MEDICAL    DIAGNOSIS. 

There  is  a  disease  allied  in  its  symptoms  to  dropsy  wliieh  lias 
attraeted  much  attention.  It  is  the  disease  pointed  out  by  Sir 
AVilliam  (Jull,  and  called  hy  Ord  mi/xcedema,  consistinii;  in  the 
progressive  invasion  of  the  body  by  a  mncus-yieldinii;  dro])sy, 
unassoeiatcd  with  all)nminuria  or  disease  of  the  heart,  but  invari- 
ably combined  with  destructive  change  and  decrease  of  the  thy- 
roid gland.  It  atl'eets  chiefly  adult  women,  who  present  swollen, 
waxy-looking  features,  with  a  circumscribed  flush  on  the  cheeks, 
and  are  markedly  anaemic,  having  an  interstitial  development  of 
fibrous  tissue,  with  an  excess  of  subcutaneous  fat.  The  skin  is 
everywhere  thickened  and  rough,  is  devoid  of  perspiration,  and 
the  puffy  integuments  do  not  pit,  or  pit  but  slightly,  on  pressure. 
The  hands  are  often  swollen  and  misshaped,  the  nails  are  brittle ; 
there  is  loss  of  teeth  and  of  the  hair.  The  temperature  is  apt  to 
be  below  the  normal,  the  excretion  of  urea  to  be  diminished.  The 
movements  of  the  limbs  are  slow  and  languid ;  the  gait  is  uncer- 
tain ;  sensation  is  impaired  ;  there  is  irritability  of  temper,  with 
increasing  hebetude,  monotonous  voice,  slow,  drawling  speech ; 
finally,  aberration  of  mind  may  supervene.  The  disease,  so 
similar  to  a  cretinoid  state,  may  be  artificially  produced  by  the 
removal  of  the  thyroid  gland.* 

Dropsy,  according  to  the  Eapidity  of  its  Development. 

Dropsy  may  come  on  suddenly,  or  be  gradually  developed. 
The  first  is  called  acute  or  active  dropsy ;  the  second,  chronic 
dropsy.  To  the  latter  class  belong  the  majority  of  instances  of 
the  forms  of  dropsy  just  discussed,  in  which  the  watery  accumula- 
tion is  thought  to  arise  from  defective  action  of  the  absorbent  ves- 
sels, or  in  which,  in  other  words,  the  dropsy  is  passive.  Acute 
dropsy  has  active  symptoms  much  like  those  of  an  inflammatory 
fever.  The  effusion  takes  place  suddenly,  and  in  consequence  of 
exposure  to  cold  and  wet,  or  of  checked  perspiration.  In  the  vast 
majority  of  examples  it  is  accompanied  by  albumen  in  the  urine, 
and  is,  in  truth,  due  to  an  affection  of  the  kidneys.  Yet  there 
are  cases  of  acute  dropsy  which  arc  not  of  renal  origin,  and  in 
which  the  rapid  occurrence  of  universal  anasarca  is  not  suscep- 
tible of  being  traced  directly  to  a  definite  lesion. 

*  Henrot,  Progres  Medical,  Sept.  1883. 


CHAPTER    IX. 

DISEASES   OF   THE   BLOOD-VESSELS. 

Only  a  short  description  of  these  will  here  be  given,  partly 
because  many  of  the  diseases  of  the  arteries  and  veins  have 
already  been  mentioned  in  connection  with  other  maladies,  and 
partly  because  the  knowledge  we  have  of  a  number  of  them  is  still 
pathological  rather  than  clinical. 

Diseases  of  the  Arteries. 

The  principal  of  these  are  inflammation  and  atheromatous 
changes. 

Arteritis. — Inflammation  may  attack  the  outer  coat,  periarte- 
ritis, the  inner  coat,  endarteritis^  or  all  the  coats,  general  arteritis. 
All  these  processes  may  be  the  result  of  rheumatism,  of  gout,  of 
syphilis,  of  lead  poisoning,  or  of  inflammation  spreading  from 
surrounding  textures. 

In  periarteritis  the  last-named  is  the  most  common  cause.  The 
large  arteries  are  the  ones  that  are  pre-eminently  affected,  and 
inflammation  of  the  external  coat  of  the  thoracic  aorta  is  more 
often  encountered  than  that  of  any  other  artery.  It  may  be 
acute ;  occasionally  it  takes  its  origin  in  inflammation  of  the  inner 
coat.  It  may  lead  to  suppuration,  and,  the  pus  finding  its  way 
into  the  calibre  of  the  vessels,  pyaemia  and  metastatic  abscesses 
are  caused.  But  it  is  not  possible  to  make  a  certain  diagnosis  of 
the  condition. 

There  is  a  peculiar  disease  of  the  arteries,  periarteritis  nodosa, 
which,  with  the  signs  of  acute  desquamative  nephritis  and  fever, 
gives  rise  to  small  swellings  under  the  skin,  to  rapid  loss  of  mus- 
cular power  with  deficient  electro-muscular  contractility,  and  to 
such  severe  muscular  pains  that  they  are  readily  mistaken  for 

763 


764  MEDICAL   DIAGNOSIS. 

those  of  the  triehinous  affection.*  •  But  the  history  of  the  ail- 
ment, the  signs  of  the  thickening  of  the  vessels,  and,  if  necessary, 
an  examination  of  the  muscles,  will  throw  light  on  the  cause  of 
the  muscular  distress. 

Endarteritis  is  almost  always  chronic,  and  chronic  endarteritis 
is  most  commonly  due  to  rheumatism,  to  gout,  to  the  poisonous 
influence  of  lead  or  of  arsenic,  or  is  seen  in  connection  with  con- 
tracted kidney.  As  regards  the  latter,  the  question  may  arise  as 
to  whether  it  has  caused  the  chronic  inflammation  of  the  arteries 
or  is  a  mere  coexisting  affection  owing  to  the  same  general  morbid 
process.  Arthur  V.  Meigs  f  in  several  able  papers  urges  this 
view,  and  I  believe  it  is  generally  the  true  explanation.  It  is  cer- 
tain that  chronic  endarteritis  is  found  without  Bright's  disease,  or 
preceding  it,  and  gives  rise  to  symptoms  by  which  it  can  usually, 
be  recognized. 

The  inflammatorv  thickening  of  the  intima  of  the  arteries  and 
arterioles  starts  as  simple  inflammation  of  the  lining,  but  may 
extend  to  some  degree  into  the  veins.  The  symptoms  to  which 
chronic  endarteritis  gives  rise  are  epistaxis,  or  hemorrhages  into 
internal  organs,  such  as  the  brain  or  the  lungs ;  oedema  without 
recognizable  cause ;  attacks  of  bronchitis  or  catarrhal  pneumo- 
nia ;  and  torpor  of  the  liver.  An  appearance  of  prominence  of 
the  smaller  vessels  and  tlieir  greater  resistance  show  the  fully- 
developed  disease,  and  we  are  then  able  to  find  marked  nervous 
symptoms,  such  as  vertigo,  loss  of  memory,  general  want  of 
power  in  the  limbs,  and  anaemia.  Valve-changes  may  also  pre- 
sent themselves,  and  albumen  and  casts  in  the  urine,  and  other 
signs  of  kidney  affection.  But  these  do  not  necessarily  occur. 
Again,  there  are  cases  in  which  they  seem  to  precede  the  endar- 
teritis. The  visceral  complications  of  the  malady  make  state- 
ments about  the  temperature  uncertain,  but  I  believe  that  it  is 
persistently  slightly  elevated.  Endarteritis  is  at  times  compen- 
satory in  slowing  of  the  blood-current. | 

Extensive  inflammation  of  the  arteries,  a  general  arteritis,  is  a 
very  rare  affection,  and  when  it  happens  it  is  acute.     In  a  few 


*  Kussmaul  and  Maier,  quoted  in  Schmidt's  Jahrb.,  No.  8,  1868. 
t  Transact.  College  of  Physicians  of  Philadelphia,  1888  and  1889. 
X  Thoma,  Virchow's  Archiv,  April,  1888. 


DISEASES   OF   THE   BLOOD-VESSELS.  766 

instances  of  rheumatism  we  find  acute  arteritis  arising,  and  espe- 
cially inflammation  of  the  fibrous  structures  of  the  aorta.  This 
condition  may  be  suspected  should  we  observe  intense  general 
uneasiness  and  distress,  with  pain,  increased  jjulsation,  a  distinct 
murmur  in  the  course  of  the  vessel,  and  tumultuous  action  of  the 
heart  without  there  being  obvious  signs  of  disease  of  that  organ 
present.  Still,  the  diagnosis  is  never  a  positive  one.  The  result 
of  the  inflammation,  particularly  of  the  acute  endarteritis  which 
forms  part  of  it, — seen,  too,  when  this  alone  is  present, — is  that 
the  blood  may  clot,  and  thrombi  or  emboli,  as  well  as  pyaemia, 
result.  The  coagula  that  are  formed  break  away,  and  occasion 
embolism,  generally  in  the  smaller  peripheral  vessels ;  though 
thrombi  may  also  develop  in  the  larger  vessels,  and  pysemic  fever 
result.  It  is  generally  impossible  to  recognize  the  malady  until 
after  the  coagula  occur,  and  then  signs  of  narrowing  of  the  calibre 
of  a  vessel,  with  a  localized  murmur,  may  give  us  the  clue  to  the 
cause  of  the  symptoms.  Haematomata  may  form  after  embolic 
arteritis  and  consequent  perforation.* 

Atheromatous  Changes. — These  are  the  common  results 
of  processes  of  decay  occurring  especially  in  persons  of  advanced 
years.  But  we  may  also  find  them  in  chronic  Bright's  disease,  in 
syphilis,  and  in  lead  poisoning,  and  they  may  be  so  much  mixed 
up  with  the  signs  of  chronic  endarteritis  that  it  is  frequently  im- 
possible to  separate  the  manifestations  of  the  maladies.  In  truth, 
even  when  the  atheromatous  changes  are  predominant  they  are 
not  always  easy  of  recognition.  These  alterations,  happening  in 
internal  arteries,  are  beyond  the  accurate  discernment  of  the  phy- 
sician. He  may  infer  that  they  exist,  if  a  distinct  systolic  bloM'- 
ing  sound  be  heard  in  the  track  of  the  aorta  or  its  branches,  in  a 
person  who  is  not  markedly  anaemic,  who  is  past  middle  life, — 
and  therefore  at  an  age  at  which  these  kinds  of  changes  of  tis- 
sues happen, — and  in  whom  no  cardiac  murmurs,  or  only  faint 
cardiac  murmurs,  are  perceived.  But  it  is  chiefly  by  the  age 
of  the  patient,  the  general  circumstances  of  the  case,  the  rigid 
resisting  superficial  arteries,  often  irregular  to  the  touch,  and  the 
gradual  development  of  cardiac  enlargement  from  the  resistance 
to  the  circulation,  that  a  conclusion  as  to  the  meaning  of  the 

*  Eushton  Parker,  Transact.  Clinical  Society  of  London,  188L 


766  MEDICAL    DIAGNOSIS. 

j)liyslc':il  signs  is  arrived  at.  Tlieso  changes  in  the  arteries  are 
important  in  themselves,  and  important  also  because  they  lead  to 
throml)i  and  are  often  the  first  step  toward  the  laceration  or 
the  dilatation  of  the  vessels, — in  other  words,  toward  the  estab- 
lishment of  an  aneurism,  which  may  be  miliary  aneurism,  as  in 
the  brain  and  lungs,  or  a  large  aneurism,  as  in  the  thoracic  and 
abdominal  aorta.  The  atheromatous  change  may  be  so  great  as 
to  cause  almost  complete  occlusion  of  large  arteries,  as  of  the 
common  carotid. 

Diseases  of  the  Veins. 

The  chief  affection  of  the  veins  in  a  diagnostic  point  of  view 
is  inflammation. 

Phlebitis. — This  is  met  with  by  the  surgeon  much  oftener 
than  by  the  physician,  who  encounters  it  more  especially  in  affec- 
tions of  internal  organs,  such  as  the  liver,  and  has  to  study  it  in 
connection  with  the  formation  of  thrombi,  and  metastatic  abscesses 
to  which  it  leads;  as,  for  instance,  in  inflammation  of  the  veins  of 
the  liver.  But  the  most  common  form  of  phlebitis  which  comes 
under  the  cognizance  of  the  medical  practitioner  is  milk  leg,  or 
phlegmasia  alba  dolens.  Here  we  have  usually  phlebitis  with  an 
obstruction  by  a  coagulum  of  the  venous  circulation  in  the  affected 
limb,  and  in  the  coagulum  cellular  elements  and  connective  tissue 
and  fine  vessels  are  found.*  There  are  also  cases  of  thrombosis 
without  inflammation  of  the  veins.  The  leg  becomes  painful, 
swollen,  shiny,  and  oedematous.  The  femoral  vein  is  tender  and 
blocked  by  a  clot ;  sometimes  this  is  in  the  crural.  The  disease 
is  seen  in  puerperal  women,  or  as  a  sequel  of  typhoid  fever  or  of 
chlorosis.  It  is,  with  the  rarest  exceptions,  one-sided.  The  pain 
in  the  leg  may  cause  it  to  be  mistaken  for  rheumatism,  but  the 
one-sided  swelling  and  the  oedema  distinguish  it.  Among  its 
early  and  significant  symptoms  is  pain  on  pressing  the  calf  of  the 
leg  on  the  affected  side. 

Diseases  of  the  Capillaries. 

Some  of  the  organic  diseases  of  the  capillaries  belong  to  the 
arterio-sclerosis  in  Bright's  disease,  or  to  the  waxy  degeneration 

*  Damaschino,  Bull.  Soc.  Med.  des  Hop.,  1880. 


DISEASES    OF   THE    BLOOD-VESSELS.  767 

in  purpura.  It  is  difficult  to  say  what  tlie  functional  disorders 
are,  for  many  of  them  are  regarded  as  forming  part  of  the  per- 
ipheral diseases  of  the  nervous  system,  and  the  affection  of  the 
arterioles  and  of  the  capillaries  is  a  mere  vaso-motor  spasm  in  con- 
nection with  the  neurosis.  This  is  supposed  to  be  the  case  in 
the  anomalous  localized  sensations  of  cold  which  some  patients 
have  in  particular  parts  of  the  body,  though  their  persistency  is 
unlike  the  history  of  a  spasm.  The  painful  flushings  of  the  feet 
bespeak  temporary  excessive  dilatation  of  the  fine  vessels.  The 
so-called  "  dead  fingers"  are  regarded  as  a  spasm  of  the  arterioles. 
They  are  most  common  in  emotional  women,  but  they  have  also 
been  observed  in  men.*  The  finger-tips  become  white  and  numb, 
warmth  and  feeling  returning  after  a  variable  time.  An  attempt 
has  been  made  to  prove  a  very  close  connection  with  Bright's  dis- 
ease, but  the  dead-finger  symptom  is  not  characteristic  of  this. 
The  disorder  may  happen  only  at  night,  forming  part  of  a  pass- 
ing loss  of  power  and  sensation, — the  so-called  "night  palsy." 
It  may  disappear  with  old  age.f 

A  spasm  of  the  minute  vessels  of  more  permanent  character 
may  lead  to  profound  disturbance  of  nutrition  in  a  part,  even  to 
its  destruction.  This  is  the  case  in  the  so-called  symmetrical  gan- 
grene, or  "  Raynaud's  disease."  It  is  a  remarkable  neurosis,  pro- 
ducing purple  discolorations,  which  are  very  painful  and  on  which 
bullse  form.  These  symmetrical  patches  of  blood-stasis  or  local 
asphyxia  lead  to  gangrene,  which,  however,  does  not  terminate 
fatally,  and  is  generally  completed  within  ten  days.  The  malady 
is  often  seen  in  the  hands,  beginning  in  or  certainly  affecting  cor- 
responding fingers.  The  patches  of  local  asphyxia,  believed  to 
be  due  to  spasm  of  the  arterioles,  may  recur  for  months  again  and 
again  without  the  disorder  causing  mortification  of  the  skin,  or 
this  may  take  place  in  any  attack. .  The  disease  may  not  happen  in 
the  fingers  or  the  toes,  but  on  the  exterior  surface  of  the  forearm 
and  below  the  knee.  By  far  the  greatest  number  of  cases  occur 
in  winter,  and  the  disease  is  thought  to  be  allied  to  paroxysmal 
hsematinuria.  But  neuritis  of  the  affected  part  has  been  found 
by  a  number  of  recent  observers. 

*  J.  E.  Squire,  Lancet,  Dec.  6,  1886. 

f  Donaldson,  ib. 


CHAPTER  X. 

DISEASES   OF   THE   BLOOD. 

Ix  the  following  sketch  I  shall  attempt  to  describe  only  those 
diseases  of  the  blood  which  are  seemingly,  for  the  most  part, 
idiopathic,  and  may  be  recognized  by  well-marked  clinical  traits. 
Prominent  among  these,  and  to  a  certain  extent  characteristic 
of  all  blood  disorders,  are  general  debility,  a  changed  aspect  of 
the  raucons  membranes  and  of  the  skin,  especially  in  color,  and 
alterations  of  nutrition. 

In  the  investigation  of  diseases  of  the  blood  the  microscope  is 
of  the  first  importance.  It  informs  us  with  regard  to  the  relative 
proportions  of  the  white  and  red  globules,  and  exhibits  the  pecu- 
liar homogeneous,  fibrinous  blood-plates  or  Iitematoblasts,  the 
nature  of  which  is  still  uncertain.  It  tells  us  something  as  to 
what  part  of  the  blood-making  organs  the  former  are  derived 
from  ;  it  indicates  whether  the  red  globules  are  of  the  right  color, 
whether  their  outline  is  regular,  whether  they  form  rouleaux 
properly,  and  whether  their  number  is  decreased.  In  this  re- 
spect recent  research  has  aided  us  much  by  supplying  us  with 
accurate  means  of  computation. 

Besides  the  method  of  estimating  the  number  of  corpuscles, 
there  are  instruments  made  for  the  purpose  of  testing  the  amount 
of  haemoglobin  each  corpuscle  contains.  The  method  of  deter- 
mination of  the  globular  richness  of  the  blood  introduced  by 
Vierordt,  in  1854,  was  to  allow  a  stated  amount  of  a  definite  di- 
lution of  the  blood  to  dry  upon  a  glass  slide,  and  subsequently 
by  the  aid  of  the  micrometer  to  count  the  number  of  the  globules. 
Imperfect  as  it  was,  by  it  he  ascertained  that  the  normal  number 
of  blood-corpuscles  in  a  healthy  male  adult  was  between  five  and 
six  millions  to  a  cubic  millimetre,  and  that  in  certain  diseases 
this  number  was  much  diminished.  Clinical  observers  confirmed 
these  observations,  and  subsequent  improvements  have  rendered  the 
768 


DISEASES   OF   THE   BLOOD.  769 

apparatus  more  precise  and  made  the  results  more  accurate.  The 
forms  of  apparatus  now  mostly  in  use  arc  the  compte-globulc 
of  Malassez,  the  hematimetre  of  Hayem  and  Nachct,  the  ha^macy- 
tometer  of  Gowers,  and  the  hsemacytometer  of  Zeiss.  To  these 
may  be  added  a  new  form  more  recently  introduced  by  Malassez, 
which  he  terras  his  graduated  moist-chamber  globule-counter. 

The  Zeiss  hsemacytometer  consists  of  three  parts  :  first,  a  gradu- 
ated pipette  or  mixing-vessel,  with  rubber  tube  attached  ;  second, 
a  counting-cell  on  an  object-slide  made  of  ground  glass  ;  third,  a 
cover-glass  with  ground  level  surfaces. 

When  counting  the  red  corpuscles  of  the  human  blood,  the  tip 
of  the  finger  should  be  thoroughly  cleaned,  the  middle  finger  of 
the  left  hand  being  generally  selected.  By  rubbing  the  end  of 
the  finger  with  a  coarse  towel  a  slight  hypersemia  is  induced, 
so  that  a  cut  with  a  spear-pointed  needle  will  permit  of  the  flow 
of  a  drop  of  blood  sufficiently  large  for  examination.  The  tip 
of  the  pipette  is  placed  into  this  drop,  and  the  blood  carefully 
drawn  up  to  the  mark  1, — i.e.,  one  cubic  millimetre.  After 
this  has  been  accomplished,  the  tip  should  be  cleaned  by  means 
of  a  soft  cloth  and  the  pipette  inserted  into  a  carefully-filtered 
ten  per  cent,  solution  of  sodium  sulphate.  This  is  drawn  up  into 
the  tube  until  the  bulb  is  filled  to  the  mark  101.  The  blood 
and  fluid  are  then  thoroughly  mixed  by  shaking  the  tube,  hold- 
ing the  finger  over  the  tip  of  the  pipette,  that  the  liquid  may  not 
escape.  After  the  mixture  has  been  thoroughly  effected,  half  of 
the  fluid  in  the  bulb  is  blown  out,  and  the  drop  that  follows  is 
allowed  to  flow  on  to  the  previously  cleaned  floor  of  the  counting- 
cell.  The  cover-glass  is  then  immediately  placed  in  position,  and 
the  apparatus  allowed  to  rest  quietly  upon  a  horizontal  surface  for 
a  few  moments,  that  the  corpuscles  may  be  permitted  to  settle. 
For  the  success  of  this  operation  perfect  cleanliness  must  be  main- 
tained throughout. 

In  order  to  make  the  examination,  the  slide  should  be  placed 
in  the  stand  of  the  microscope  and  held  in  a  horizontal  position, 
that  the  corpuscles  may  not  be  displaced.  The  cover-glass  should 
lie  accurately ;  great  care  should  be  taken  that  no  liquid  flow 
between  the  cover-glass  and  the  ring.  It  is  important  that  the 
drop  of  blood  mixture  shall  remain  standing  in  the  centre  of  the 
cell,  and  that  by  the  spreading  of  the  cell  the  under  surface  of 

49 


770 


MEDICAL    DIAGNOSIS. 


the  cover-glass  shall  be  in  contact  with  the  mixture  for  several 
millimetres.  Usinti;  a  one-fourth  or  a  one-fifth  objective  elass  to 
bring  into  view  the  divisions  cut  upon  tlie  floors  of  the  cell,  we 
find  that  upon  these  lie  the  red  blood-corpuscles.  The  numbei- 
of  corpuscles  in  each  space  is  then  noted.  Through  each  fifth 
■horizontal  and  vertical  row  of  the  lines  an  additional  line  is 
drawn,  for  the  purpose  of  fixing  more  readily  the  position  of  the 
squares  counted. 

Each  field  of  the  net-work  contains  a  surface  of  one  four-hun- 
dredth of  a  square  millimetre.     The  distance  of  the  cell-floor 


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Artificial  capillarj-  of  Malassez,  magtiified  100  diameters. 


from  the  under  surface  of  the  cover-glass  is  one-tenth  of  a  milli- 
metre. Each  square,  therefore,  represents  the  one  four-thousandth 
of  a  cubic  millimetre.  The  number  of  corpuscles  contained  in 
one  of  these  cells  multiplied  by  the  number  of  times  the  blood 
has  been  diluted  will  give  the  amount  of  corpuscles  contained  in 
the  one  four-thousandth  of  a  cubic  millimetre.  The  amount  con- 
tained in  a  cubic  millimetre  can,  therefore,  be  found  by  multiply- 
ing by  four  thousand.  The  surest  method  is  to  count  at  least 
forty  spaces,  to  take  the  average  of  them  all,  and  proceed  as 
above.  It  is  sometimes  rather  difficult  to  distinguish  the  white 
from  the  red  blood-corpuscles,  and  this  difficulty  is  obviated  by 


DISEASES    OF    THE    BLOOD, 


771 


Fig.  56. 


using  the  one-third  per  cent,  solution  of  acetic  acid  instead  of  the 
sodium  sulphate  solution  when  the  white  blood-corpuscles  are  to 
be  estimated,  and  employing  a  larger  quantity  of  lAood  in  the  tube, 
say  five  cubic  millimetres.  This  solution  dis- 
solves all  the  red  blood-corpuscles  and  leaves  only 
the  white  in  the  field.  Another  method  for  com- 
puting the  white  corpuscles  is  to  use  with  the  salt 
solution  a  few  drops  of  a  one  per  cent,  solution  of 
gentian  violet ;  this  leaves  the  red  blood-corpuscles 
unaltered  and  stains  the  leucocytes  a  deep  violet. 

The  hsemacytometer  of  Gowers  is  about  the 
same  as  that  of  Zeiss,  differing  mainly  in  the 
number  of  divisions  on  the  cell,  each  space  being 
but  one-tenth  of  a  millimetre  in  length.  The 
method  of  preparing  the  blood  solution  is  not  so 
convenient  as  that  of  Zeiss.  A  hsemic  unit  of 
five  millions  of  corpuscles  to  one  cubic  millimetre 
of  blood  is  assumed. 

By  means  of  Malassez's  instrument  results  of 
great  accuracy  can  be  obtained,  but  it  is  neither  so 
manageable  nor  so  certain  as  that  of  Zeiss.  The 
blood  in  this  instrument  has  to  run  along  a  tube, 
and  the  tendency  the  white  corpuscles  have  to 
adhere  to  the  sides  of  the  vessel  makes  this  im- 
practicable. 

By  the  original  method  of  Malassez  the  blood 
was  diluted  with  artificial  serum  so  that  it  repre- 
sented Y^  or  2^  of  the  original.  A  small 
amount  was  then  introduced  into  a  flattened  capil- 
lary tube  of  known  capacity,  and  with  the  mi- 
crometer eye-piece  the  globules  were  counted  in 
the  capillary  tube  of  a  certain  length,  say  500  micro-millimetres. 
The  capacity  of  this  length  of  the  tube  in  parts  of  a  cubic  milli- 
metre being  already  known,  the  entire  number  of  globules  in  a 
cubic  millimetre  of  the  undiluted  blood  was  easily  determined 
by  calculation.     For  the  purpose  of  diluting  the  blood  *  Potain's 


> 


Potiiin's  pipette. 


*  Malassez  recommends  for  artificial  serum  a  five  or  six  per  cent,  solution 
of  sodium  sulphate,  having  a  specific  gravity  of  1020  to  1024. 


772  MEDICAL    DIAGNOSIS. 

capillarv  pipette  (Fio-.  06)  is  well  adapted.  It  is  so  eonstrneted 
as  to  contain  in  a  imrt  of  its  extent  a  reservoir  imprisoning;  a 
glass  bead,  the  capacity  of  this  chamber  being  exactly  one  hnn- 
dred  times  that  of  the  capillary  tnbe  leading  to  it.  To  the  opposite 
extremity  is  attached  a  rubber  tnbe,  which  being  placed  between 
the  lips  causes  the  fluid  to  ascend  to  the  desired  extent  by  aspira- 
tion, or  by  blowing  through  it  the  tube  may  be  emptied. 

IMalassez,  in  describing  his  new  globule-counter,*  criticises  the 
hfemic  unit  of  Gowers,  and  denies  that  such  a  proportion  as  it 

Fig.  57. 


.i3 


Graduated  moist-cliamber  uf  ^I;il;isscz.    In  the  lower  figure  the  compressor  is  seen  attached  to  the 

slide. 


exjiresses  bears  any  absolute  relation  to  the  normal  globular  rich- 
ness of  the  blood,  because  there  is  no  fixed  norm,  the  average 
five  million  being  only  a  mean  and  not  a  constant.  In  other 
words,  the  number  of  blood-cells  to  the  millimetre  cube  in  health 
varies  in  different  individuals,  and  in  the  same  individual  at  cer- 
tain hours  in  the  day.  Malasscz,  M'ithout  abandoning  his  origi- 
nal design,  recommends  an  improved  cell  for  microscopic  work. 
It  consists  of  a  thick  glass  slide  having  ground  in  the  centre  of 
its  upjier  surface  a  ring  or  circular  trench  one  and  a  half  milli- 
metres in  breadth  and  one  millimetre  in  depth,  which  leaves  a 


*  Arch,  de  Phys.,  1880,  and  Oct.  1882. 


DISEASES    OF   THE    BLOOD. 


773 


plateau  of  about  seveu  iiiilliuietrcs  in  diameter  separated  from 
the  remnant  of  the  surface  of  tlie  slide  by  a  narrow  gutter,  so  that 
when  the  cover  is  in  place  water  may  be  ])laced  under  it  by  cajiil- 
lary  attraction,  but  cannot  reach  the  islet  in  the  centre.  In  tin's 
way  any  fluid  may  be  protected  from  evaporation  while  under 
examination, — a  very  important  precaution  while  counting  blood- 
cells.  Outside  of  this  -ring  three  or  four  holes  pierce  the  glass 
slide,  from  which  the  points  of  screws  are  made  to  project,  so  as 


Blood-mixture  as  seen  with  tlie  square  mlcrometei-  ruling  of  the  moist-chamber  of  Malassez :  mag- 
nified 250  diameters. 


exactly  to  maintain  tlie  cover-glass  at  one-fifth  of  a  millimetre 
above  the  surface.  A  micrometer  scale  is  engraved  upon  the 
object-holder,  which  obviates  the  necessity  of  regulating  the  micro- 
scope in  advance.  The  scale  on  the  object-holder  is  divided  into 
rectangular  spaces  one-fourth  of  a  millimetre  long  by  one-fifth 
broad,  representing  each  one-twentieth  of  a  square  millimetre. 
Each  of  these  is  subdivided  into  twenty  little  blocks,  as  shown  in 
the  figure  (Fig.  58),  each  one-twentieth  millimetre  square. 


M-i  MEDICAL    DIAGNOSIS. 

In  order  that  the  cover-oln.ss  shall  be  i)laced  (|iiiekly  and  exactly 
upon  the  sereNv-puints  and  the  di»j)  of  diluted  blood,  the  cover  is 
attached  tea  frame  nioving  upon  a  hinge,  which  is  clamped  to  the 
slide.  The  glass  slide  is  kept  perfectly  horizontal,  and,  if  it  is 
feared  that  the  object  examined  will  dry,  a  little  water  or  the 
blood-mixture  may  be  dropped  upon  it,  so  as  to  surround  the 
circle  already  mentioned.  The  number  of  globules  contained  in 
twenty  of  the  little  squares  is  now  to  be  counted,  and  if  the  fluid 
used  be  a  centesimal  dilution  it  is  only  necessary  to  add  four 
ciphers  to  the  number  in  order  to  obtain  the  number  in  a  cubic 
millimetre,  since  the  large  squares  represent  the  ten-thousandth 
part  of  this  unit.  To  be  exact,  several  observations  should  be 
made.  The  greatest  care  is  required  after  each  enumeration,  in 
order  to  insure  cleanliness. 

Whatever  be  the  method  used  in  counting  the  blood-corpuscles, 
a  number  of  observations  should  always  be  made.  Since  from 
any  of  the  instruments  but  an  approximate  result  can  be  obtained, 
the  mean  of  several  observations  will  give  us  estimates  sufficient  for 
all  practical  purposes.  In  the  several  forms  of  annemia  it  is  neces- 
sary to  obtain  a  correct  knowledge  of  the  state  of  the  blood,  not 
only  as  to  the  number  of  its  corpuscles,  but  also  as  to  the  amount 
of  haemoglobin  it  contains,  for  in  the  diagnosis  of  any  disease  of 
the  blood  it  is  absolutely  necessary  to  know  the  relationship  exist- 
ing between  them.  Since  normal  blood  contains  five  millions  of  red 
blood-corpuscles  or  thereabout,  nearly  ten  thousand  white  blood- 
corpuscles,  and  two  hundred  and  fifty  thousand  blood-plaques  or 
hrematoblasts,*  to  the  cubic  millimetre,  and  since  each  red  cor- 
puscle holds  in  suspension  a  certain  percentage  of  hemoglobin, 
any  marked  variation  in  the  number  of  corpuscles  or  in  the 
amount  of  haemoglobin  must  be  indicative  of  an  abnormal  state. 
Examination  of  the  blood  in  disease  shows  that  these  amounts 
vary,  and  there  may  be  any  of  the  conditions  mentioned  in  the 
following  table,  in  which  the  arrangement  of  Graeber  is  some- 
what followed.  R.  stands  for  red  corjauscles,  W.  for  white  cor- 
puscles, H.  for  hsemoglobin. 

K.  increased,  W.  normal,  H.  increased, — Plethora,  polycytlnemia. 
K.  normal,  W.  normal,  H.  normal, — Health. 

*  Hayeni,  Du  Sang,  Paris,  1889. 


DISEASES    OF   THE    BLOOD.  775 

R.  normal,  W.  normal,  H.  diminished, — Chlorosis.* 

R.  diminished,  W.  normal,  H.  diminished, — Anaemia. 

R.   Greatly  diminished,   W.   normal,    H.    increased    (relatively), — Pernicious 

anaemia. 
R.  normal,  W.  increased,  H.  normal, — Leucocytosis. 

R.  diminished,  W.  increased,  H.  diminished  (relatively), — Leucocythasmia. 
R.  diminished,  "W.  increased,  H.  diminished, — Splenic  anaemia. f 
R.  diminished,  W.  normal,  H.  diminished, — Lymphatic  anajmia  when  glands 

are  enlarged. 

In  estimating  the  number  of  blood-corpuscles  the  age  and  the 
sex  must  be  taken  into  account.  In  healthy  women  the  number 
per  millimetre  cube  is  somewhat  less  than  in  healthy  men,  being 
about  four  million  five  hundred  thousand  ;  in  new-born  infants  it 
often  exceeds  six  million,  as  both  Hayem^  and  Henry  §  have 
found  by  repeated  observations.  But  in  the  infant  the  constitu- 
tion of  the  blood  is  remarkable  for  its  variability. 

The  white  blood-corpuscles  in  normal  healthy  blood  are  in  the 
proportion  of  about  one  to  six  hundred  red,  this  varying  somewhat 
in  different  individuals  without  being  indicative  of  disease.  When 
the  red  blood-corpuscles  are  reduced  in  number,  the  proportion  is 
greater,  without  there  being  necessarily  an  increase  in  the  number 
of  leucocytes.  The  safest  method  of  procedure  is  to  estimate  the 
number  of  white  corpuscles  to  the  cubic  millimetre,  so  that  any 
increase  or  diminution  in  their  amount  will  give  their  true  condi- 
tion irrespective  of  the  change  in  the  number  of  red  disks ;  the 
same  importance  may  be  attached  to  the  hsemoglobin,  for  often 
this  is  only  relatively  diminished,  when  if  the  red  blood-corpus- 
cles were  estimated  we  should  find  that  each  disk  had  its  normal 
amount  of  heemoglobin.  The  apparatuses  for  estimating  the 
hsemoglobin  are  the  hsemoglobinometer  of  Gowers,  Fleischl's 
hsemometer,  H^nocque's  hsematoscope,  and  the  hsemochromometer 
of  Malassez. 

Of  these,  Gowers's  is  the  most  convenient,  though  the  hsemom- 
eter of  Fleischl  is  more  accurate.  Henocque's  is  especially  valua- 
ble for  spectroscopic  examination.     Gowers's    apparatus    consists 

*  This  is  not  invariable :  there  may  also  be  some  diminution  of  the  red. 

t  Striimpell,  Banti. 

X  Du  Sang  et  de  ses  Alterations  anatomiques,  Paris,  1889. 

§  Amer.  Journ.  Med.  Sci.,  April,  1890. 


re 


MEDICAL    DIAGNOSIS. 


of  two  gla.ss  tubes  of  oxaotly  the  same  size.  One  contains  a 
standaixl  of  the  tint  of  the  dilution  of  twenty  cubic  millimetres 
of  blood  with  one  thousand  nine  hundred  and  eiolity  cubic  milli- 
metres of  water.     The  second  tube  is  graduated  to  one  hundred 


Fig.  59. 


The  haenioglobinometer  of  Gowers.  A,  bottle  with  pipette-stopper;  B,  capillary 
pipette;  C,  graduated  tule ;  D,  tube  containing  st.indard  tint,  fixed  in  E,  a  wooden 
block;  F,  guarded  needle. 

degrees,  which  equal  two  cubic  centimetres.  The  twenty  cubic 
millimetres  of  blood  are  measured  by  a  capillary  pipette.  This 
quantity  of  the  blood  to  be  tested  is  dropped  to  the  bottom  of  the 
graduated  tube,  a  few  drops  of  distilled  water  being  first  placed 
in  the  latter,  and  tlie  mixture  is  rapidly  agitated,  to  prevent  the 
coagulation  of  the  blood.  The  distilled  water  is  then  added  drop 
by  drop  until  the  tint  of  the  solution  is  the  same  as  that  of  the 
standard,  and  the  amount  of  the  water  added  indicates  the  amount 
of  hsemoglobin. 

Fleischl's  hsemometer*  consists  of  a  stand  to  which  is  attached 
a  reflector  made  of  card-board.  On  the  under  surface  of  the 
plate  there  are  two  grooves,  into  which  slides  the  frame,  hold- 
ing in  position  a  wedge-shaped  glass  colored  red,  the  intensity  of 
the  hue  being  graduated  from  zero  to  one  hundred  and  twenty 
degrees.     The  frame  is  moved  by  means  of  a  thumb-screw  so  that 

*  Wiener  Med.  Jahrbiicher,  1885,  pp.  42-5-445:  Das  Haeraometer. 


DISEASES   OF   THE   BLOOD.  777 

when  it  is  operated  the  tinted  glass  passes  beneath  one  of  the 
compartments  of  the  comparing  vessel.  The  horizontal  projec- 
tion of  the  partition  of  this  vessel  should  fall  directly  upon  the 
outer  edge  of  the  glass  wedge  when  the  instrument  is  properly 
adjusted.  In  operating  the  instrument,  care  should  be  taken  to 
have  everything  perfectly  clean.  Accompanying  each  apparatus 
are  a  glass  pipette  for  dropping  the  water  into  the  compartments, 
and  several  minute  capillary  tubes  for  securing  the  blood. 

The  compartments — that  is,  the  blood  and  wedge  compartments 
— :are  filled  almost  to  the  top  with  distilled  water,  and  the  vessel  is 
placed  in  situ.  The  instrument  should  then  be  so  arranged  and  the 
reflector  so  adjusted  as  to  secure  the  full  rays  of  light  from  either  a 
candle,  a  lamp,  or  a  gas-flame.  Before  securing  the  blood,  the  tip 
of  the  middle  finger  of  the  left  hand  should  be  carefully  cleansed 
and  dried.  The  automatic  blood-pipette,  with  a  capacity  of  six 
and  a  half  cubic  millimetres,  and  about  eight  millimetres  long,  to 
which  is  attached  a  frail  wire  for  its  manipulation,  should  always 
be  greased,  to  prevent  the  blood  from  adhering  to  its  sides.  This 
is  dipped  into  the  blood  sideways,  to  facilitate  the  flow  into  the 
tube  :  the  greatest  accuracy  is  essential  to  the  correctness  of  the 
test.  With  as  little  delay  as  possible  the  tube  is  then  placed 
into  the  blood  compartment  and  its  contents  allowed  to  escape, 
aiding  by  gently  moving  the  tube  back  and  forth  along  its 
own  axis.  The  diluted  blood  remaining  in  the  tube  is  then 
washed  out  by  means  of  the  pipette  and  allowed  to  flow  into  the 
compartment.  This  is  filled,  as  is  the  wedge  compartment,  with 
distilled  water,  care  being  taken  not  to  allow  the  fluid  in  the  two 
chambers  to  run  together. 

The  blood  is  now  ready  for  examination.  In  looking  at  the 
compartment  the  eyes  should  be  shaded,  that  the  direct  rays  of 
light  shall  not  strike  in  and  thus  cause  error  in  the  observa- 
tion. The  thumb-screw  is  turned,  which  slowly  moves  the  wedge 
from  right  to  left ;  this  movement  is  continued  until  the  eye  can 
perceive  no  difference  in  color  between  the  two  compartments : 
should  the  difference  be  imperceptible  for  a  considerable  distance, 
then  the  point  at  which  the  color  appears  lighter  and  that  at 
which  it  appears  darker  should  be  both  noted  and  the  mean  taken. 
The  number  of  degrees — that  is,  the  percentage  of  hsemoglobiu — 
will  be  found  on  the  movable  slide. 


i  iS  MEDICAL   DIAGNOSIS. 

Anaemia. — Poverty  of  blood  is  met  Avith  as  a  eonsequence  of 
prufuse  or  frequently-recurring  hemorrhages,  of  insufficient  nour- 
ishment", of  affections  which  prevent  the  nutriment  taken  from 
being  jiroperly  absorbed  or  assimilated,  thus  impoverishing  the 
blood  by  depriving  it  of  its  most  needed  constituents,  and  of  pro- 
fuse chronic  discharges,  Avhich  drain  the  blood  of  many  of  its  im- 
portant elements,  and  especially  of  its  albumen.  Besides  these 
causes  of  anaemia,  "\ve  find  it  occasioned  by  particular  poisons,  as 
by  malaria,  by  syphilis,  by  uterine  comj)laints,  by  the  retention  of 
noxious  ingredients  in  the  blood,  or  by  diseases  of  certain  glands. 
Again,  it  is  sometimes  encountered  without  our  being  able  to 
trace  it  to  any  obvious  source.  But  under  all  these  circumstances, 
except  in  tlic  anannia  after  hemorrhage,  where  all  the  constitu- 
ents of  the  blood  are  diminished  together,  we  have  to  deal  with 
a  watery  blood  deficient  in  red  corpuscles,  and  the  corpuscles  are 
often  badly  shaped,  and  shrunken  at  their  edges.  The  haemo- 
globin may  be  diminished  or  may  not  be  materially  changed. 

Whatever  may  have  given  rise  to  the  anaemia,  the  manifesta- 
tions of  the  disorder  are  much  the  same.  The  patient  is  weak 
and  pale;  his  lips  and  tongue  have  lost  their  red  color;  the  eye  is 
pearly ;  his  pulse  is  feeble,  but  generally  accelerated  ;  the  appetite 
is  deficient  or  depraved  ;  the  bowels  are  apt  to  be  costive.  Exer- 
cise induces  great  fatigue,  shortness  of  breath,  and  palpitation ; 
and  the  disturbance  of  the  heart  may  be  associated  with  cardiac 
murmurs  or  with  blowing  sounds  in  the  cervical  veins,  and  is 
sometimes  so  persistent  as  to  lead,  as  will  be  found  elsewhere  de- 
scribed, to  structural  changes  in  the  heart.  In  some  cases,  further, 
we  meet,  among  the  symptoms  of  the  affection,  with  obstinate 
headache  and  with  dropsy,  and  in  many  with  a  persistent  pain  in 
the  left  side,  in  the  region  of  the  spleen. 

Chlorosis. — Here  the  pallid,  wax-like  countenance,  the  very 
pale  lips,  and  the  pearly  eye  afford  unmistakable  evidence  of  the 
deterioration  of  the  blood,  consisting  chiefly  in  great  deficiency  of 
hsemoo-lobulin,  Avhicli  is  generallv  much  more  marked  than  the 
reduction  in  the  red  corpuscles,  which  indeed  may  be  of  almost 
normal  amount.  The  complaint  is  especially  encountered  in 
young  females,  and  is,  as  a  rule,  associated  with  amenorrhoea. 
Indeed,  many  restrict  the  term  to  the  obvious  anaemia  combined 
with  suppression  of  the  menses,  so  often  affecting  girls  about  the 


DISEASES   OF   THE   BLOOD.  779 

age  of  puberty.  In  pure  chlorosis,  organic  diseases  of  the  gastro- 
intestinal apparatus,  of  the  spleen  and  lymphatic  glands,  or  of  the 
lungs  and  kidneys,  are  absent;  the  temperature  shows  a  slight 
rise ;  the  nutrition  of  the  body  is  fairly  well  kept  up  ;  the  urine 
is  pale  and  abundant,  containing  but  a  small  amount  of  phos- 
phates ;  the  nervous  system  is  irritable.  Pigmentation  about  the 
second  joints  of  the  fingers,  on  their  dorsal  surface,  has  been 
noticed.*  Sometimes  these  symptoms  of  chlorosis  happen  before 
puberty;  or  there  are  relapses  of  the  malady  in  middle  age.  Boys 
about  the  age  of  puberty  may  also  develop  the  manifestations  of 
chlorosis.  Virchow  has  pointed  out  the  frequent  association  of 
chlorosis  with  narrowing  of  the  aorta  and  of  the  great  arteries, 
and  such  cases  are  distinguished  by  obstinate  relapses.  There  is 
a  variety  of  chlorosis  in  connection  wdth  tubercle,  at  times  pre- 
ceding it. 

Pernicious  Anaemia. — This  is  a  fatal  form  of  anaemia,  which 
was  well  known,  at  least  in  some  of  its  varieties,  to  Addison,  and 
which,  since  the  recent  researches  of  Biermer,  has  actively  en- 
o;ao;ed  the  attention  of  the  medical  world.  It  is  an  extreme  anse- 
mia  advancing  steadily,  or  with  remissions,  toward  a  fatal  end- 
ing ;  yet  no  cause  can  be  detected  for  the  profound  and  disastrous 
alteration  the  blood  is  undergoing.  To  pernicious  ansemia  belong 
most  of  the  cases  of  "  essential"  or  "  idiopathic  ansemia"  w^hich, 
since  the  time  of  Addison,  have  been  reported. 

The  disorder  is  most  frequent  in  women,  and  has  been  especially 
observed  in  child-bearing  women  after  several  pregnancies ;  still, 
it  also  often  happens  in  men,  especially  before  the  age  of  forty. 
It  sometimes  seems  to  have  its  origin  in  long-continued  dyspepsia 
or  diarrhoea,  and  atrophy  of  the  gastric  tubules ;  or  to  arise  after 
protracted  hemorrhages  or  incessant  worry, — after  indeed  slowly 
but  steadily-acting  debilitating  influences ;  and  it  has  been  noted 
to  arise  after  nervous  shock,  or  to  be  of  parasitic  origin,  and  due  to 
worms,  sometimes  to  a  tape-worm, — bothryocephalus  latus.f  But 
in  the  majority  of  instances  it  originates  seemingly  without  cause, 
and,  although  it  has  periods  of  deceptive  improvement  which  may 


*  Bouchard. 

t  Schmidt's  Jahrb.,  i.,  1881  ;  also  ih.,  No.  10,  1887;  and  Berl.  Klin.  Wo- 
chenschr.,  No.  40,  1886;  also  Deutsches  Arch,  fur  Klin.  Med.,  Bd.  sxxix. 


780  MEDICAL   DIAGNOSIS. 

last  for  months,  or,  as  I  have  known,  even  for  a  year,  it  progresses 
relentlessly  toward  a  fatal  issue.*  It  is  true  that  some  cases  of 
recovery  have  been  recorded  ;  but  of  these  it  is  ix)t  quite  certain 
that  tliey  presented  all  the  characteristic  symptoms. 

There  is  an  insidious  beginning,  except  at  times  when  the  anae- 
mia develops  itself  in  the  pregnant  state.  Pale  tongue,  bloodless 
lips,  pearly  eye,  becoming  paler,  more  bloodless,  more  pearly, 
from  week  to  week ;  breathlessness ;  palpitation  of  the  lieart,  es- 
pecially on  exertion  ;  weak  digestion  ;  constipation,  or  constipation 
alternating  with  diarrhoea ;  loud  systolic  murmurs  in  the  heart,  and 
venous  hum  in  the  jugulars;  vertigo;  a  marked  lemon-colored 
hue  of  the  skin  about  the  large  joints,  at  times  jaundice ;  finally 
extreme  exhaustion,  sluggishness  of  mind,  fainting-fits,  and  dropsy, 
without  persistent  albumen  in  the  urine,  or  disease  of  the  liver, 
or  enlargement  or  valvular  disease  of  the  heart,  to  account  for  it, 
— are  the  prominent  symptoms.  In  the  later  stages,  too,  hemor- 
rhages from  the  nose  and  from  the  gums  are  not  uncommon  ;  and 
hemorrhages  from  the  uterus  or  from  the  kidneys,  or  into  the  skin 
and  into  the  retina,  may  also  be  noticed ;  the  latter  especially  is 
very  frequent.  Yet,  notwithstanding  all  these  grave  signs,  the 
body  appears  well  nourished ;  there  is  certainly  no  decided  ema- 
ciation, except  in  instances  in  which  fever  is  more  than  commonly 
marked.  Now,  fever  is  a  significant  feature  of  progressive  per- 
nicious anajmia ;  it  has  been  present  in  every  case  that  I  have  met 
with.  It  is  not  an  early  symptom,  belonging  to  the  full  develop- 
ment or  to  the  latter  part  of  the  disease.  It  is  of  very  irregular 
type,  and  not  of  high  intensity,  the  temperature  rarely  exceeding 
103°  F.  It  is  apt  to  be  continued,  or  to  show  occasional  exacer- 
bations, followed  by  remissions,  the  febrile  state  lasting  for  days, 
or  even  for  a  week  or  two  at  a  time ;  then  there  arc  periods  of 
shorter  or  longer  duration  when  it  wholly  disappears,  to  come  on 
again  in  an  outbreak  attended  with  all  the  usual  signs  of  a  febrile 
paroxysm  for  which  no  cause  is  apparent.  Toward  tlie  end  of  tlie 
case  it  is  not  unusual  for  the  anaemic  fever  to  have  entirely  ceased, 
and  for  the  temperature  to  have  fallen  below  the  normal  standard. 
The  disease  may  run  an  acute  course.f 

*  See  also  case  with  remissions  in  Schmidt's  Jahrb.,  No.  4,  1882. 
t  Ljintener,  Rev.  ]Med.,  Louvuin,  1883,  il. 


DISEASES   OF   THE    BLOOD.  781 

The  state  of  the  blood  in  this  perilous  malady  has  naturally 
been  made  a  subject  of  minute  investigation.  The  red  globules 
are  strikingly  diminished  in  number, — to  about  a  million  and  a 
half;  the  white  corpuscles  are  not  relatively  altered,  or  they  may 
remain  normal,  and  seem  to  be  increased,  because  the  red  globules 
are  so  much  fewer.  The  haemoglobin  is  very  generally  increased,* 
the  white  corpuscles  are  normal  or  diminished,  the  pale  hajmato- 
blasts  are  diminished  and  may  quickly  assume  irregular  shapes. 
The  shape  of  the  red  corpuscles  was  stated  by  Eichhorst  to  be 
characteristically  changed,  in  so  far  at  least  that  the  blood  contains 
a  quantity  of  ill-developed,  small,  spherical,  highly-colored  red 
corpuscles.  But  these  are  not  pathognomonic  ;  for  they  have  been 
found  by  Cohnheim  in  medullary  leukaemia,  by  Greenfield  in 
lymphadenoma,  and,  on  the  other  hand,  in  a  well-marked  instance 
of  pernicious  anaemia  examined  by  Bradburyf  they  were  absent. 
They  are  the  corpuscles  arrested  in  their  growth.  Besides  this 
there  are  giant  cells  of  irregular  shape,  on  which  Hay  em  J  lays 
great  stress,  also  on  many  very  large  normal-looking  red  corpus- 
cles, some  of  which  are,  however,  nucleated.  Nucleated  red  cor- 
puscles were  detected  in  the  blood  of  all  the  patients  examined 
by  Howard  :  §  the  blood  seems  to  revert  to  a  lower  type.  A 
much  larger  proportion  than  is  found  normally  of  small  disks  of 
deep  color  is  regarded  as  important  by  Pye  Smith.  ||  The  accom- 
panying cut  (Fig.  60),  from  a  well-marked  instance  of  the  disease, 
shows  the  irregular  shape  of  the  corpuscles  and  their  varied  size 
and  appearance  ;  some  are  nucleated. 

Of  the  real  cause  of  the  disease  we  are  in  ignorance.  No  con- 
stant lesion  of  the  blood-malving  glands  has  been  found.  The 
structure  of  the  spleen  and  of  the  lymphatic  glands  is  not  altered ; 
the  marrow  of  the  bones  may  or  may  not  be,T[  though  cases  in 
w'hich  it  is  are  thought  to  be  instances  of  myelogenous  pseudo- 


*  Hayem,  Du  Sang,  Paris,  1889. 

t  British  Medical  Journal,  Aug.  14,  1880. 

X  Op.  cit. 

I  Montreal  General  Hospital  Keports,  vol.  i.,  1880. 

II  Guy's  Hospital  Keports,  xxvi.,  3d  Series,  1883. 

T[  Pepper,  Amer.  Journ.  Med.  Sci.,  Oct.  1875;  see  also  Cohnheim,  Yir- 
chow's  Arehiv,  Bd.  Ixviii.,  and  Waldstein,  Arch.  f.  Path.  Anat.,  Berlin, 
1883,  xci. 


782  :\IEDICAL   DIAGNOSIS. 

Icuka-'mia  ratlier  tlian  of  pcM'nicions  aiin?inia.  Pcrliaps  the  most 
constant  lesion  is  fatty  degeneration  of  the  heart,  often  associated 
with  tlie  same  change  in  the  inner  coat  of  tlie  hirge  arteries. 
Hijuter'*'  has   recently  bronght   forward   strong    proof  that   the 

Fig.  go. 


Blood  in  pernicious  anajmia. 

characteristic  anatomical  change  is  the  presence  of  an  excess  of 
iron  in  the  liver,  the  seat  of  disintegration  of  the  corpuscles  being 
chiefly  in  the  portal  circulation. 

The  diagnosis  of  pernicious  ansemia  is  never  an  easy  one,  for 
the  reason  that  it  is  difficult  to  be  quite  certain  that  no  ob.scure 
and  latent  disease  exists  which  would  account  for  the  exhaustion 
and  the  progressive  impoverishment  of  the  blood.  Indeed,  it  is 
only  after  the  most  careful  and  repeated  examinations  of  all  the 
organs  of  the  body  and  the  most  searching  inquiry  into  the  his- 
tory of  the  case  that  we  are  justified  in  making  the  diagnosis  of 
pernicious  anfemia.  I  have  more  than  once  known  ill-developed 
organic  disease  of  the  stomach,  especially  gastric  cancer,  where  the 

*  Lancet,  London  Practitioner,  Aucj.  1888. 


DISEASES   OF   THE   BLOOD.  783 

tumor  could  not  be  discerned,  or  contracted  kidney,  with  but  little 
albumen  in  the  urine,  regarded  as  a  typical  illustration  of  the 
malady,  until  the  autopsy  revealed  the  true  cause  of  the  fatal 
exhaustion.  With  reference  to  the  former  aifection  the  error  is 
all  the  more  likely  to  happen  because  symptoms  of  gastric  dis- 
order are  not  unusual  in  progressive  anaemia ;  with  reference  to 
disease  of  the  kidney  the  misleading  part  is  that  a  trace  of  albu- 
men is  occasionally  present  in  progressive  ansemia.  But  it  is  not 
persistent ;  and  microscopical  examination  of  the  urine  will  tell 
us  the  real  amount  of  kidney  affection. 

Diseases  of  the  heart  may  be  mistaken  for  pernicious  anaemia.  A 
fatty  heart,  in  an  elderly  person,  with  or  without  valvular  disease, 
with  failure  of  strength,  and  with  the  peculiar  pallid,  sickly  look 
occasioned  by  the  malady,  may  mislead.  But  the  long  duration  of 
such  cases,  and  the  absence  of  fever,  are  strong  points  in  the  case. 
Indeed,  the  error  is  apt  to  be  the  other  way, — that,  overlooking 
the  symptoms  of  profound  aneemia  and  general  failure,  we  regard 
the  murmurs  and  the  other  cardiac  symptoms  which  are  associated 
with  the  fatty  heart  of  pernicious  ansemia  as  pointing  to  a  disease 
of  the  heart  alone.  The  physical  signs  will  not  always  assist :  the 
murmurs  may  be  very  distinct  and  loud. 

If  we  have  excluded  any  organic  disease  that  could  account  for 
the  ansemia,  we  turn  to  the  diseases  of  the  blood  itself  to  obtain 
an  explanation  of  the  symptoms.  And  here  we  find  first  that 
pernicious  ansemia  differs  from  ordinary  ansemia  by  the  absence 
of  the  history  of  the  causes  that  commonly  give  rise  to  the  anaemic 
state,  such  as  acute  diseases,  malaria,  tubercular  or  cancerous 
cachexia,  loss  of  blood,  and  the  like,  but  above  all  by  its  relent- 
less course  and  the  little  influence  the  most  nourishing  diet  and 
courses  of  iron  have  on  it.  Moreover,  the  loudness  of  the  cardiac 
murmurs,  the  slight  emaciation,  and  the  irregular  outbreaks  of 
fever  are  very  significant.  The  outbreaks  of  fever,  the  presence 
of  dropsy,  though  moderate,  the  retinal  extravasations,  the  other 
hemorrhagic  symptoms,  and  the  unyielding  blood-change,  sepa- 
rate pernicious  anaemia  from  the  chlorosis  so  common  at  the  age 
of  puberty  in  girls.  The  pernicious  malady  sometimes  seems  to 
develop  out  of  a  long-standing  chlorosis,  and  then  the  grave 
symptoms  just  spoken  of  tell  its  supervention.  The  same  grave 
symptoms  happen  also,  at  least  the  hemorrhages  are  as  frequent, 


784  MEDICAL   DIAGNOSIS. 

and  the  fever  and  dropsy  may  happen,  in  leul-remia  and  in  pseudo- 
leukoemia.  But  the  great  increase  in  the  white  eitrpuseh^s,  the 
tumefaetion  of  the  spleen,  or  the  affections  of  other  blood-making 
parts,  distinguish  the  former  mahuly ;  and  pseudo-leukaMnia,  while 
the  blood  microscopically  will  not  dilfcr  materially,  exhibits  the 
enlarged  lymphatic  glands,  their  progressive  invasion,  the  lym- 
phoid tumors,  the  abdominal  j)ains,  and  the  steadily-increasing 
emaciation  so  characteristic  of  the  disease. 

There  are  other  forms  of  idiopathic  anfemia  of  which  we  cannot 
clearly  recognize  the  cause,  that  we  shall  probably  soon  be  able  to 
separate  into  groups.  But  for  the  present  we  have  to  admit  that 
cases  may  happen  which  cannot  be  classified. 

Leukaemia. — This  morbid  state  consists  in  a  decided  increase 
of  the  white  corpuscles  and  a  decrease  of  the  red.  Under  the 
microscope  the  Avhite  globules  of  the  blood,  instead  of  bearing 
the  normal  proportion  of  about  1  to  50  of  the  red,  are  found  in 
the  proportion  of  1  to  6,  or  even  of  1  to  0.5,  and  cases  have  been 
met  with  in  which  near  the  point  of  death  the  white  corpuscles 
have  exceeded  the  red  as  higli  as  five  times.  Besides  the  increase 
of  white  corpuscles  and  the  diminution  of  the  red,  peculiar,  color- 
less, shining,  elongated  octahedral  crystals  have  been  pointed  out 
by  Neumann  and  by  Charcot.  Jaksch*  has  shown  that  the 
blood  is  rich  in  peptone,  although  this  substance  is  rarely  met 
Avith  in  the  urine  in  leukoemia. 

The  abnormal  condition  exists  in  connection  with  hypertrophy 
of  the  spleen,  "  splenic  leuksemia,"  or  of  the  liver,  with  other  dis- 
eases of  this  viscera,  and  with  various  malignant  or  non-malignant 
affections  of  the  lymphatic  glands,  "  lymphatic  leukemia,"  or  of 
the  thyroid  body,  especially  with  an  increase  of  the  cellular  ele- 
ments. But  none  of  the  blood-glands  is  so  constantly  and  so 
markedly  affected  as  the  spleen.  It  has  been  stated  by  Neumann 
and  others  that  a  large  production  of  lymphoid  cells  happens  in 
the  marrow  of  the  bones,  and  there  is  a  "  myelogenous"  or  medul- 
lary form  of  leuksemia. 

The  disorder  may  occur  at  all  ages;  it  is  more  common  in  men 
than  in  women.  Leukremia  is  consequent  upon  obstinate  intermit- 
tents  with  decided  enlargement  of  the  spleen,  syphilis,  over-exer- 

*  Wiener  Med.  Presse,  Oct.  1882. 


DISEASES   OP   THE   BLOOD.  785 

tion,  long- continued  mental  depression,  chronic  intestinal  catarrh, 
and  blows  on  the  splenic  region.  The  form  affecting  the  marrow 
of  the  bones  frequently  results  from  injury  to  the  bones.  But  in 
many  cases  of  leuksemia  no  adequate  cause  can  be  detected.  Its 
beginning  is  usually  gradual  and  ill  defined  ;  sometimes  it  clearly 
follows  other  diseases.  When  fully  developed,  it  often  occasions, 
besides  the  obvious  pallor  and  the  cachectic  appearance,  exhaus- 
tion, diarrhoea,  extremely  hurried  breathing,  hemorrhages  from 
various  parts,  especially  from  the  nose,  profuse  sweating,  sliglit 
rise  of  temperature  in  the  evening,  increase  of  uric  acid  in  the 
urine,  fleeting  abdominal  pains,  and  dropsy  dependent  upon  the 
enlargement  of  the  spleen  or  of  the  liver  or  upon  the  leuksemic 
new  formations  in  the  latter.  In  some  cases  a  swelling  of  the 
glands  on  both  sides  of  the  throat,  attended  with  inflammation 
of  the  mucous  membrane  of  the  mouth  and  the  pharynx,  and 
followed  by  swelling  of  the  axillary  and  the  inguinal  glands, 
precedes  the  enlargement  of  the  liver  and  of  the  spleen.*  Indeed, 
glandular  tumors  are  often  present ;  the  glands  of  the  groin  are, 
as  a  rule,  enlarged.  There  is  disturbance  of  vision,  connected 
with  retinal  clianges,  also  melancholy,  and  in  some  instances  deaf- 
ness, and  peritoneal  or  pleural  inflammations.  Pain  in  the  bones, 
too,  particularly  in  the  sternum,  is  observed.  The  medullary  or 
myelogenous  variety  is  especially  marked  by  pain,  which  is  in- 
creased or  developed  by  pressure  over  the  sternum  and  ribs  and 
over  other  affected  bones,  f 

The  diagnosis  of  leuksemia  is  possible  only  by  the  microscopical 
examination  of  the  blood,  which  detects  the  decided  increase  of 
the  white  corpuscles.  In  the  most  common  variety,  splenic  leu- 
ksemia, we  may  also  be  able  even  early  to  discern  the  enlargement 
of  the  spleen,  and  find  the  evidences  of  a  cachexia  in  the  look  of 
the  patient,  and  in  recurring  epistaxis.  But  it  is  the  microscopical 
examination  of  the  blood  alone  which  enables  us  to  distinguish 
leuksemic  swelling  of  the  spleen  from  its  other  affections.  And 
to  have  a  definite  diagnostic  meaning  the  white  corpuscles  must 
be  decidedly  and  permanently  increased ;  for  a  mere  transitory, 


*  Hosier,  in  Virchow's  Archiv,  xliii. 

f  Mosler,  Berlin.  Klin.  'Wochenschrift,  xiii.,  1876;  and  Schmidt's  Jalirb., 
No.  10,  1877. 

50 


786  MEDICAL   DIAGNOSIS. 

slight  increase  may  occur  in  other  diseases  of  the  spleen.  Some 
corpuscles  are  larger,  some  smaller,  than  normal,  and  many  show 
fatty  changes ;  but  in  splenic  leuknemia  the  white  corpuscles  are 
mostly  large.  In  both  varieties  the  red  corpuscles  are  badly 
shaped.  Lymphatic  leukaemia  is  chieHy  recognized  by  the  marked 
swelling  of  the  lymphatic  glands,  while  the  spleen  is  less  ob- 
viously affected.  In  the  blood  the  white  corpuscles  derived  from 
the  lymphatic  glands  are  smaller  than  those  coming  from  the 
spleen,  and  have  a  well -developed  nucleus.  But  it  is  very  diffi- 
cult to  judge  a  case  by  these  traits.  Large  round  cor})uscles  con- 
taining granules  which  by  ether  and  chloroform  are  found  to  be 
fatty  are  stated  to  be  derived  from  the  marrow  of  the  bones,  and, 
if  abundant,  to  bespeak  medullary  leukaemia.*  Hayemf  found 
that  nucleated  red  corpuscles  were  habitually  present,  and  that 
the  very  large  white  cells  were  destitute  of  amoeboid  movement. 

Lymphadenoma. — As  regards  the  symptoms,  the  closest  simi- 
larity to  leukremia  is  presented  by  the  affection  described  as  lymph- 
adenoma,  pseudo-leukiemia,  or  Uodgkin's  diseane.  It  consists  in 
an  enlargement  of  the  lymphatic  glands  of  the  body,  often  with 
lymphoid  growths  in  other  parts,  which  soon  becomes  com])licatcd 
with  extreme  ansemia,  with  weakness  and  signs  of  cachexia,  with 
diarrhoea,  with  dropsy,  M'ith  cardiac  palpitation,  shortness  of 
breath,  and  attacks  of  suffocation,  with  tendency  to  profuse  bleed- 
ings and  to  bed-sores,  and  leads  usually  in  the  course  of  not  many 
months,  or,  at  farthest,  of  a  few  years,  to  death.  There  is  often 
a  sense  of  fulness  in  the  abdomen,  attended  with  violent  pains ; 
the  temperature  in  advanced  cases  shows  mostly  an  evening  rise. 
Some  of  the  superficial  lymphatics  are  first  affected,  others  fol- 
low ;  the  disorder  then  extends  more  decidedly,  the  spleen  and 
the  liver  increase  in  size,  other  organs,  too,  may  become  involved, 
and  lymphoid  tumors  develop  in  various  parts  of  the  body ;  but 
among  the  internal  organs  the  spleen  is  the  one  most  constantly 
disturbed. 

The  disease  generally  begins  in  the  cervical  glands  ;  far  less 
frequently  does  it  show  itself  first  in  the  inguinal  or  in  the  axil- 
lary glands ;  still  less  frequently  in  the  bronchial  or  in  other  in- 
ternal glands.     The  affection  occui's  much  oftener  in  men  than  in 

*  Schmidfs  Jahrb.,  No.  10,  1877.  f  Op.  cit. 


DISEASES    OF    THE    BLOOD.  787 

women.  It  mostly  happens  between  the  aiijes  of  ten  and  thirty- 
five  and  of  fifty  and  sixty,  but  is  not  very  uncommon  in  young 
children.  Its  cause  is  unknown  ;  it  certainly  lias  no  definite  con- 
nection with  either  scrofula  or  syphilis. 

The  chief  anatomical  lesion  is  found  to  be  an  augmented 
formation  of  the  structure  of  the  glands.  The  spleen  is  either 
simply  hypertrophied  or  is  the  seat  of  numerous  disseminated 
lymphoid  growths ;  in  neither  case  is  it  apt  to  attain  to  any  very 
great  size.  At  times  the  follicles  at  the  base  of  the  tongue,  in  the 
tonsils,  and  in  the  intestines  share  in  the  morbid  process ;  changes 
in  the  bone-marrow  are  rare.  The  blood  shows  deficiency  in  red 
globules,  but  otherwise  no  constant  alteration.  Slight  increase 
of  leucocytes  has  been  occasionally  noticed,  especially  during  the 
later  stages ;  but  even  then  the  white  corpuscles  are  small. 

It  is  this  difference  in  the  state  of  the  blood  that  makes  the 
chief  difference  between  pseudo-leukaemia  and  leukasmia,  in  which 
there  may  be  glandular  enlargements.  Further,  leukaemia  is  a 
disease,  as  a  rule,  of  longer  duration,  and  the  splenic  enlargement 
is  generally  much  more  marked.  Rare  cases  of  diffused  lymphatic 
cancer  closely  resemble  Hodgkin's  disease ;  so  closely  that  they 
are  undistinguishable,  except  by  the  history  of  the  case  and  by  a 
microscopical  examination  of  any  of  the  tumors  that  may  have 
been  removed ;  the  spleen  is  not  involved,  while  the  organs  con- 
tiguous to  the  glandular  cancer  are  likely  to  be  more  rapidly  im- 
plicated. In  sarcoma  of  the  lymphatic  glands  the  disease  is  at  first 
strictly  local,  and  then,  if  it  spread,  invades  not  the  lymphatic 
tissues  specially,  but  any  part  of  the  body.  Local  gland  lym- 
phomas are  separated  from  Hodgkin's  disease  by  their  local  char- 
acter, by  their  want  of  extension,  and  by  the  absence  of  marked 
cachexia.  Scrofulous  glands,  unlike  lymphadenoma,  enlarge  rap- 
idly, have  thickened  tissue  around  them,  and  are  apt  to  undergo 
cheesy  degeneration,  or  to  soften  and  suppurate.  Moreover,  they 
are  associated  with  the  general  evidences  of  scrofula. 

In  the  early  stages  of  lymphadenoma  a  diagnosis  is  impos- 
sible, and  we  are  at  a  loss  to  account  for  the  increasing  signs  of 
cachexia,  until  the  involvement  of  the  lymphatic  glands  in  rapid 
succession,  and  their  quick  growth,  or  the  speedy  formation  of 
other  lymphoid  tumors  under  the  skin  or  in  other  parts  of  the 
body,  clear  up  all  doubt.     There  will  also  be  great  uncertainty  in 


788  MEDICAL    DIAGNOSIS. 

all  those  instances  in  wliieh  tiie  growths  happen  first  in  internal 
fflands  or  strnetnres, — as  in  the  bronchial  o;lands  and  the  medias- 
tinuni,  producing  severe  broneliitis,  extreme  dyspnoea,  and  signs 
of  venous  stagnation  in  the  veins  of  the  upper  part  of  the  body ; 
or  as  in  the  glands  around  the  biliary  duets,  giving  rise  to  jaun- 
dice ;  or  as  in  growths  in  the  spinal  cord  leading  to  paraplegia, 
— until  the  external  swellings  explain  the  case.  The  kidney 
is  not  an  organ  tliat  often  suffers  primarily  ;  the  occurrence  of 
more  than  a  mere  trace  of  albumen  shows  that  it  has  become  im- 
plicated from  parenchymatous  changes  or  disseminate  lymphoid 
growths. 

Addison's  Disease. — While  seeking  for  the  explanation  of 
puzzling  cases  of  anauuia,  Addison  discovered  that  a  peculiar 
anaemia  always  occurs  in  connection  with  a  diseased  condition 
of  the  supra-renal  capsules,  and  is  characterized  by  distressing 
languor  and  great  general  prostration,  remarkable  feebleness  of 
the  heart's  action,  loss  of  appetite,  obstinate  vomiting,  and  a 
singular  alteration  of  the  skin.  This  consists  in  a  dingy  or 
smoky  hue  of  the  surface  ;  or  the  color  may  be  of  a  deep  amber 
or  chestnut  brown,  or  the  altered  skin  may  have  a  bronzed  tinge. 
The  change  of  color  begins  on  exposed  parts,  such  as  the  face 
and  neck  and  the  back  of  the  hands,  and  deepens  first  there ;  but 
we  also  soon  find  it  marked  in  parts  which  are  naturally  the  seat 
of  much  pigment,  such  as  the  axillae,  the  groins,  and  the  areolae 
of  the  nipples.  It  is  also  marked  around  the  umbilicus,  on  the 
penis,  and  on  the  scrotum,  and  is  dependent  upon  a  layer  of  pig- 
ment in  the  rete  mucosum.  The  sldn  remains  soft  and  smooth, 
and  becomes  in  large  portions  uniformly  discolored,  gradually 
deepening,  and  often  presenting  a  hue  on  the  face  and  hands  like 
that  of  a  mulatto.  Any  irritation  of  the  skin  is  folloAved  by  dark 
streaks.  Discoloration  in  patches  is  both  less  constant  and  less 
significant  than  extensive  alteration  of  hue ;  yet  the  darkening  in 
undoubted  cases  may  occur  in  patches,  which  are  usually  most 
obv^ious  on  the  face  or  the  superior  extremities.  Tlie  patient  may 
seem  at  first  sight  to  be  jaundiced  ;  but  the  pearly  whiteness  of 
the  conjunctiva  soon  dispels  such  an  idea.  The  nails  are  pale 
and  bluish ;  the  tongue  may  have  patches  of  dark  color ;  the  body 
and  breath  at  times  exhale  an  offensive  odor  ;  and  the  blood  has 
been  found  to  contain  an  excess  of  white  corpuscles  and  a  slight 


DISEASES   OF   THE    BLOOD.  789 

decrease  of  the  red,  although  it  generally  does  not  undergo  any 
important  or  characteristic  change.* 

With  reference  to  the  other  symptoms,  the  most  conclusive  of 
them  are  remarkable  prostration,  generally  without  any  marked 
waste  of  the  body,  feebleness  of  heart's  action  and  of  pulse,  and 
obvious  anaemia.  In  most  cases,  but  far  from  in  all,  these  symp- 
toms precede  the  discoloration  of  the  skin ;  and  they  are  not 
unfrequently  associated  with  pain  in  the  back  and  with  gastro- 
intestinal irritation,  with  breathlessness  upon  exertion,  with  ver- 
tigo, and  with  dimness  of  sight  or  impaired  hearing.  A  peculiar 
odor  of  the  body,  like  that  perceived  in  the  colored  race,  was  ob- 
served in  two  cases  placed  on  record  by  Mr.  Hutchinson.  In  the 
last  stages  of  the  malady  the  temperature  falls  below  the  norm. 

Death  may  take  place  gradually  from  the  constantly-growing 
asthenia ;  or  it  may  occur  suddenly,  and  where  the  amount  of 
prostration  does  not  appear  so  excessive  as  to  foreshadow  it. 
According  to  the  elaboi'ate  researches  of  Wilks,  the  destruction 
of  the  capsules  is  dependent  upon  a  peculiar  scrofulous  degenera- 
tion ;  while  Greenhow  states  it  to  be  due  to  an  inflammatory  exu- 
dation of  low  type.  Should  this  prove  to  be  the  correct  view  of 
the  case, — should,  in  other  words,  the  nature  of  the  disease  of  the 
capsules  influence  its  symptoms  more  than  the  mere  fact  of  their 
being  diseased, — it  would  explain  why  in  some  cases  of  absence 
of  the  gland,  or  of  its  cancerous  degeneration  or  suppui'ation,  no 
signs  of  Addison's  disease  existed.  It  would  then  be  a. specific 
disease  of  the  supra-renal  capsules  which  produces  the  manifesta- 
tions of  Addison's  disease.  With  reference  to  the  nature  of  the 
affection,  however,  tuberculous  disease  of  the  glands  has  been 
found  without  bronzing  ;t  and  tubercle-bacilli  have  been  detected 
in  the  caseous  glands.  Many  of  the  symptoms  of  the  fully- 
developed  malady  may  be  due  to  the  implication  of  the  nervous 
branches,  derived  from  the  sympathetic  and  the  pneumogastric, 
which  go  to  the  gland. 

Now,  in  the  diagnosis  of  Addison's  disease  the  alteration  of  the 
color  of  the  skin  plays  so  important  a  part  that  we  must  inquire 
'V\^hether  it  or  something  very  like  it  may  not  happen  in  other 

■*  Greenhow,  Addison's  Disease. 

f  As  in  the  case  of  Ballenghien,  Journ.  des  Sci.  Med.  de  Lille,  1888. 


790  MEDICAL    DIAGNOSIS. 

eoiiclitions.  In  persons  long  exposed  to  the  sun  a  bronzing  of  the 
face  and  neck  and  arms  ocenrs;  but  it  is  extremely  uniform; 
there  is  ti  striking  contrast  between  it  and  the  parts  that  are  not 
exposed,  including  such  as  we  find  greatly  affected  in  Addison's 
disease,  the  flexures  of  the  joints,  the  scrotum,  the  textures  around 
the  nipple  and  the  umbilicus.  Moreover,  there  is  often  robust 
rather  than  impaired  health.  In  persons  who,  in  addition  to  ex- 
posure, are  of  uncleanly  habits  and  infested  Avith  vermin,  especially 
in  elderly  persons,  a  discoloration  of  the  skin  happens  at  various 
portions  of  the  body,  often  deepest  on  the  chest,  the  abdomen,  and 
the  back,  which  is  readily  mistaken  for  the  bronzing  of  Addison's 
disease.  But  in  this  vagrants'  disease  the  discoloration  is  in  the 
superficial,  not  in  the  deeper  layers  of  the  epidermis,  and  the  dark 
cuticle  is  harsh  and  raised,  not  soft  and  smooth.  Then  alkaline 
baths  and  Avashing  with  soap  will  greatly  diminisli  the  deepened 
hue.  A  similar  bronzing  of  long  standing,  though  of  doubtful 
origin,  is  sometimes  met  with.* 

During  exhausting  lactation,  or  in  pregnancies  attended  with 
much  constitutional  disturbance,  there  may  be  marked  discolora- 
tion of  the  skin ;  yet  it  is  not  most  obvious  on  the  face,  and  the 
circumstances  of  the  case  are  important  aids  in  the  diagnosis. 
So  is  the  history  in  those  instances  in  which  a  bronze  hue  is 
]iereditary,-\  or  in  which  a  very  deceptive  discoloration  follows 
yellow  fever,  or  the  lacdarial  fevers,  or  chronic  disorders  of  the 
liver.  In  these  diseases,  too,  the  discoloration  is  not  so  great,  and 
it  is  not  marked  at  the  sites  most  affected  in  Addison's  disease. 
Greenhow  has  pointed  out  how  certain  very  long  standing  in- 
stances of  phthisis  exhibit  an  appearance  exactly  like  that  of  the 
earlier  stages  of  Addison's  disease.  Yet  the  abnormal  pigmenta- 
tion does  not  deepen  or  increase,  and  the  symptoms  remain  only 
those  of  the  pulmonary  malady.  Stains  on  the  skin  from  pnty- 
riasis  versicolor  or  from  syphilis  have  not  the  characteristic  seats 
of  Addison's  disease,  and  they  are  in  patches  and  surrounded  by 
healthy  skin,  and  certainly  the  syphilitic  affection  coexists  with 
other  significant  eruptions  or  signs. 

One  of  the  most  difficult  questions  connected  with  the  diag- 


*  Crocker,  Transact.  Clin.  Soc.  Lond.,  vol.  xiv.,  1881 ;  also  Carrington,  ib. 
t  Medical  Times  and  Gazette,  May,  1871. 


DISEASES   OF  THE   BLOOD.  791 

nosis  of  Addison's  disease  is  that  cases  occur  without  bronzinj^,  or 
with  the  discoloration  of  the  skin  so  shght  as  to  be  a  matter  of 
doubt.  Such  cases  are  generally  in  persons  who  die  before  they 
have  had  the  disease  any  length  of  time.  If  the  altered  hue  of 
the  skin  be  wanting,  the  complaint  is  undistinguishablo  from  'per- 
nicious ansemia,  though  we  may  lay  some  stress  on  the  compara- 
tive absence  of  febrile  phenomena.  Other  diseases  of  the  supra- 
renal capsules,  such  as  cancer  and  waxy  disease,  arc  also  not  to 
be  separated  from  the  peculiar  affection  of  the  gland  occasioning 
Addison's  disease,  if  bronzing  of  the  skin  be  not  present. 

The  malady,  as  Greenhow  proves,  is  very  rare  except  in  ])ersons 
employed  in  manual  labor.  In  some  instances  it  seems  to  arise 
from  grief  or  protracted  anxiety.  The  disorder  is  a  chronic  one, 
generally  lasting  for  years  ;  but  it  almost  invariably  destroys  life. 
Yet  cases  have  been  recorded  in  which  most  of  the  symptoms  of 
Addison's  disease  existed  and  which  recovered  ;  and  certainly  long 
remissions  in  the  symptoms  have  been  not  unfrequently  observed, 
and  in  these  remissions  the  discolored  skin  has  lightened. 

Fysemia. — Purulent  contamination  of  the  blood  is  an  affection 
much  more  likely  to  be  met  with  by  the  surgeon  than  by  the  phy- 
sician ;  yet  the  physician  must  be  familiar  with  its  symptoms. 
These  are,  great  depression  of  the  vital  powers,  profuse  sweats, 
rapid  pulse,  and  the  formation  of  purulent  deposits  in  different 
portions  of  the  body.  The  symptoms  may  be  of  gradual  devel- 
opment ;  but  often  they  set  in  suddenly  with  a  chill,  to  which  a 
fever  of  low  type  soon  succeeds ;  or  the  shivering  is  followed  by 
copious  sweating,  and  the  febrile  phenomena  subsequently  appear. 

The  pyemic  fever  rarely  lasts  longer  than  a  week,  and  during 
its  continuance  it  usually  presents  the  most  marked  variations  in 
temperature.  Yet  the  disease  is  not  always  alike  in  this  respect ; 
for  we  find,  as  Heubner  has  proved,  not  only  cases  in  which  the 
most  decided  increase  of  heat  is  constantly  followed  by  an  equally 
decided  decrease,  but  also  cases  in  which  there  are  febrile  attacks 
followed  by  marked  intervals  during  which  the  temperature  is 
almost  normal,  and  cases  in  which  continuous  fever  exists  with 
striking  intercurrent  rises  in  temperature.*  Still,  in  all  the  maxi- 
mum temperature  is  apt  to  be  very  high,  ranging  from  106°  to  108°. 

*  Archiv  der  H^ilkunde,  ix.,  1868. 


792  MEDICAL    DIAGNOSIS. 

The  disorder  may  arise  after  injuries  and  operations;  or  where 
sinuses  or  abscesses  exist  that  have  no  free  vent  for  the  pus;  or  in 
consequence  of  the  contamination  of  the  blood  which  happens  in 
plilebitis  or  arteritis ;  or  in  inflammation  of  the  external  coat  of 
arteries,  with  suppuration,  especially  in  the  periarteritis  of  the 
thoracic  aorta;  or  in  ulcerative  endocarditis;  or  the  jn-icmia  re- 
sults from  the  breakiuix  down  of  coaji'ula  in  the  blood-vessels;  or 
it  may  supervene  ujion  diffuse  cellular  inflammations,  or  upon 
puerperal  fever :  in  fact,  it  will  be  found  under  many  dissimilar 
circumstances.  But,  without  stop})ing  to  explain  its  varying 
sources  of  origin,  let  us  look  at  its  diagnostic  traits. 

Now,  there  are  several  complaints  with  which  pyajraia  is  likely 
to  be  confounded,  the  chief  of  which  are  typhoid  fever,  rheuma- 
tism, acute  glanders  and  fan.y,  and  acute  affections  of  the  liver. 

It  is  liable  to  be  mistaken  for  typhoid  fever,  on  account  of 
the  adynamic  character  of  the  fever,  and,  it  may  be,  the  occur- 
rence of  diarrhoea  and  of  cerebral  symptoms.  But  the  history  of 
the  case  is  very  dissimilar  :  there  is  no  eruption,  or,  if  there  be 
an  eruption,  it  consists,  as  Bristowe  so  particularly  jwints  out,  of 
sudamina  surrounded  by  a  zone  of  congestion,  and  is  therefore 
not  the  eruption  of  the  typh-fevers ;  and,  on  the  other  hand,  we 
find  in  typhoid  fever  neither  the  profuse  sweating  nor  secondary 
deposits  of  pus,  and  the  thermometry  of  the  disease  is  very  differ- 
ent. Pyaemia  may,  however,  happen  as  a  complication  of  the 
febrile  malady. 

The  pain  in  the  joints  and  their  swelling  in  succession,  the 
fever,  and  the  perspirations,  resemble  much  at  times  rheumatic 
fever.  But  the  difference  consists  in  the  greater  severity  of  the 
constitutional  phenomena  caused  by  the  poisoned  blood,  in  the 
marked  exhaustion,  in  the  rigors,  and  in  the  history  not  being 
that  of  acute  rheumatism.  JNIoreover,  the  frequent  signs  of  for- 
mation of  abscesses  in  internal  organs  or  around  the  joints,  the 
development  of  pustules  on  the  skin,  and  the  striking  redness 
of  the  tumid  joints  assist  materially  in  the  diagnosis. 

Acute  glanders  or  acute  farcy  is  a  disease  scarcely  distinguish- 
able from  pyemia,  since  it  occasions,  for  the  most  part,  the  same 
manifestations.  The  knowledge  that  the  patient  who  has  appar- 
ently pysemic  symptoms  has  been  working  among  horses,  the 
ulceration  of  the  mucous  membrane  of  the  nose,  and  the  fetid 


DISEASES   OF   THE   BLOOD.  793 

discharge  proceeding  from  it,  which  occurs  in  acute  glanders,  and 
which  is  apt  to  be  associated  with  nasal  hemorrhages,  with  an 
offensive  breath,  with  enlargement  of  the  lymphatic  glands  in 
the  vicinity  of  the  affected  mucous  membrane,  and  with  hurried 
breathing,  or  sometimes  with  gangrene  of  various  parts,  afford 
us  the  only  means  of  discrimination.  Then  we  find  a  peculiar 
tuberculated  or  pustular  eruption  which  appears  upon  the  skin, 
and  in  farcy  the  lymphatic  glands  and  vessels  specially  suffer. 
But  more  significant  than  all,  in  point  of  diagnosis,  is  being  able 
to  trace  the  distinct  history  of  the  contagion  ;  for  the  grave  coryza 
does  not  happen  in  all  forms  of  equinia, — certainly  not  in  farcy. 

Acute  afections  of  the  liver  resemble  pysemia  on  account  of  the 
jaundice  which  may  attend  the  latter  disorder ;  but  the  history 
of  the  case,  the  rigors,  the  sweats,  and  the  purulent  deposits,  dis- 
tinguish it.  But  it  must  be  remembered  that  suppurative  inflam- 
mation of  the  portal  veins  and  metastatic  abscesses  of  the  liver 
happen. 

In  conclusion,  let  us  inquire  where  and  how  the  secondary  de- 
posits are  formed.  They  may  take  place  in  the  parenchymatous 
organs,  particularly  in  the  lungs  and  the  liver ;  in  the  synovial  sacs, 
in  muscles,  or  in  areolar  tissue,  especially  in  that  under  the  skm. 
There  may  be  capillary  embolism  in  pyaemia,  not  to  be  recognized 
exce[)t  by  the  microscope.* 

If  the  altered  blood  coagulate  in  the  arteries,  or  if  from  disin- 
tegration of  fibrin  in  the  arterial  system  the  fibrinous  masses  oc- 
casion deposits  in  solid  organs,  as  in  the  liver  or  the  spleen,  we 
may  have,  with  the  similar  pathological  states,  symptoms  arising 
similar  to  those  of  true  pyaemia.  Indeed,  in  the  arterial  pysemia, 
as  it  has  been  called,  rigors,  febrile  symptoms  and  sweating,  and 
pains  in  the  joints  are  observable.  In  connection  with  the  ob- 
scure febrile  condition,  the  liver  and  the  spleen  are  often  observed 
to  increase  in  size  slowly.f    The  heart  may  or  may  not  be  affected. 

There  is  a  form  of  pyaemia,  called  by  Leube  |  spontaneous 
septico-pysemia,  which  comes  on  without  obvious  cause,  or  is 
perhaps  preceded  by  a  fall  or  a  slight  skin  wound,  in  which  the 


*  Hayem,  quoted  in  Half- Yearly  Abstract,  Jan.  1872. 

f  Samuel  Wilks,  Guy's  Hospital  Eeports   vol.  xv.,  3d  Series. 

X  Archiv  fur  Klin.  Med.,  xxii.,  1878. 


794  MEDICAL    DIAGNOSIS. 

symptoms  of  pyaemia  become  developed  with  j)ain  and  tenderness 
in  joints  and  nniseles,  eeeliymosis  of  tlie  eonjunetiva,  vesicles  in 
the  skin-  containing  blood,  extremely  high  temperature,  swelling 
of  the  spleen,  albuminous  urine,  })leurisy  or  perhajis  signs  of 
endocarditis  or  pericarditis,  stupor,  delirium,  cramps,  and  linally 
involuntary  discharges  and  coma.  The  disease,  resembling  typhus 
or  ulcerative  endocarditis,  is  to  be  distinguished  only  by  the  general 
association  of  the  symptoms. 

The  description  of  pyajniia  given  represents  it  as  an  acute  affec- 
tion, and  so  it  almost  always  is.  Yet  there  are  cases  much  slower 
in  their  course,  and  extending  over  months.  These  chronic  or 
relapsbif/  instances  of  the  disease  have  been  described  by  Paget.* 
The  symptoms  presented  are  the  same  as  in  the  acute  disorder ; 
but  the  local  evidences  of  the  complaint  are  more  often  seated  in 
diifcrent  parts  of  the  same  tissues,  and  less  frequently  in  internal 
organs.    The  malady  is  not  nearly  so  perilous  as  the  acute  disease. 

Septicaemia. — This  is  a  poisoned  state  of  the  blood,  produced 
by  mineral  and  vegetable,  but  especially  by  animal,  poisons,  such 
as  the  bites  of  venomous  serpents  or  the  absorption  of  putrid 
matters  which  have  been  generated  in  the  economy,  or  by  their 
inoculation.  The  continued  exposure  to  the  breathing  of  foul  air 
and  of  septic  gases  will  also  occasion  septicaemia.  The  symptoms 
of  the  blood-poisoning  vary  somewhat  with  the  individual  poison 
that  has  occasioned  it.  They  are,  in  the  main,  the  symptoms  of 
pyaemia,  except  that  secondary  pus  formations  belong  to  the  former 
rather  than  to  the  latter  ;  and  the  same,  of  course,  may  be  said 
of  embolism  and  its  results.  Rigors  are  frequently  observed.  In 
many  instances  the  altered  condition  of  the  blood  leads  to  hemor- 
rhages from  internal  organs,  to  petechise,  to  delirium  and  coma,  to 
extreme  rapidity  of  pulse,  to  high  temperature  with  burning  heat 
of  skin,  to  enlargement  of  the  spleen,  to  cough  and  bronchial 
catarrh,  and  to  gastric  and  intestinal  disorders.  The  blood  mi- 
nutely examined  shows  the  white  corpuscles  almost  always  greatly 
in  excess,  although  not  altered  in  character  as  they  are  apt  to  be 
in  leuk£emia ;  the  red  globules  are  diminished. f 


*  St.  Bnrthdlomew's  Hospital  Koports,  vol.  i. 

t  See  the  valuable  report  of  the  Committee  of  the  Pathological  Society  of 
London,  Transactions,  1879. 


DISEASES   OF   THE    BLOOD.  795 

Thrombosis  and  Embolism. — Althougli  in  connection  with 
endocarditis,  with  obstruction  of  the  cerebral  arteries,  and  with 
diseases  of  the  kidney,  the  phenomena  of  embolism  have  been  de- 
scribed, it  may  serve  a  useful  purpose  to  view  here  connectedly, 
though  chiefly  in  their  diagnostic  bearing,  some  of  the  results  of 
the  formation  of  the  clots  in  large  vessels  or  in  the  heart,  and  of 
their  being-  carried  alono;  with  the  current  of  the  blood  and  driven 
into  remote  vessels, — the  results,  therefore,  of  thrombosis  and  of 
embolism.  Of  these  embolism  is  the  subject  which  more  particu- 
larly concerns  the  physician  in  its  immediate  practical  bearing. 

The  embolus  may  produce  manifestations  in  the  venous  system, 
either  in  the  peripheral  veins,  or  in  the  venous  trunks  of  the 
great  internal  cavities  of  the  body  ;  or  a  portion  of  the  clot  may 
have  been  washed  into  the  pulmonary  artery  from  the  right  side 
of  the  heart;  or  it  may  have  become  impacted  in  the  arteries  of 
the  general  circulation,  in  the  larger  arteries,  or  in  those  of  fine 
calibre ;  or  it  may  have  been  propelled  into  the  very  structure  of 
organs  through  these  arteries,  as  into  the  liver-structure  through 
the  hepatic  artery,  into  the  splenic  parenchyma  through  the  splenic 
artery.  Let  us  examine  a  little  more  closely  some  of  the  symptoms 
thus  occasioned,  premising  that  arterial  embolism  is  of  much  more 
frequent  occurrence  than  the  other  forms. 

In  the  veins  thrombi  may  form,  which,  so  long  as  they  do  not 
produce  obstruction  of  the  canal,  give  rise  to  no  marked  signs.  A 
slight  hardening  and  pain  on  pressure  if  the  coagulum  be  in  one 
of  the  more  superficial  veins,  their  enlargement  if  the  clot  be  in 
a  deeper  vein,  are  apt  to  be  the  only  evidences  of  the  disordered 
condition.  But  when  the  occlusion  is  considerable,  and  especially 
when  the  collateral  circulation  is  insufficient,  oedema  is  developed 
which  may  be  attended  with  very  great  tenderness  of  the  swollen 
part,  and,  if  the  impediment  be  of  long  duration,  with  changes 
in  the  nutrition  of  the  structures  sufficient  to  produce  phlegmo- 
nous inflammation.  These  phenomena  are  encountered  in  milk- 
leg,  or  phlegmasia  alba  dolens.  In  some  cases  profuse  hemorrhages 
occur  as  a  consequence  of  the  stoppage  in  the  vein, — as  cerebral 
hemorrhages  produced  by  thrombosis  of  the  sinus,  or,  as  in  a  case 
referred  to  by  Virchow,*  enormous  hemorrhagic  infiltration  of  the 

*  Patliologie  und  Therapie,  p.  172. 


796  MEDICAL    DIAGNOSIS. 

subperitoneal  and  subcutaneous  tissues,  as  well  as  of  portions  of 
the  muscles  of  the  abdoniiual  walls,  as  the  result  of  a  coaguhun 
in  the  extei'iuil  iliac  vein,  the  epigastric,  and  the  crural  vein. 

In  exhan.stinr/  and  watitituj  diseases  blood  may  clot  in  the  veins 
or  even  in  the  heart,  without  any  clearly-marked  cause.  Gout 
may  cause  phlebitis  and  clotting  in  tiic  veins  of  the  body,  as 
Sir  James  Paget  has  pointed  out.  Again,  we  may  have  chlo- 
rosis give  rise  to  thrombosis  in  the  cavities  of  the  heart  and  the 
larger  veins,  such  as  the  feraorals,  without  phlebitis  preceding  the 
morbid  condition.* 

Now,  portions  of  the  clot,  situated  in  any  part  of  the  venous 
system,  however  remote  from  the  heart,  may  become,  by  being 
broken  off  and  driven  onward  with  the  circulation,  sources  of 
great  danger.  When  the  blood  clots  in  veins  connected  Mith 
the  portal  system,  the  detached  fragments  may  be  washed  into  the 
liver,  and  there  lead  to  secondary  abscesses.  But  when  coagula 
occur  in  the  venous  system  and  are  wholly  or  in  part  carried  away 
with  the  circulating  blood,  if  we  exclude  those  which,  from  their 
situation,  could  only  reach  the  liver,  we  generally  find  the  mani- 
festations of  disturbance  arising  in  the  heart  or  the  lungs.  Ar- 
riving at  the  right  side  of  the  heart,  the  concretion,  if  at  all  large, 
or  if  it  become  so  by  serving  as  a  nucleus  for  a  larger  clot,  oc- 
casions symptoms  of  exhaustion  and  collapse ;  an  intermitting, 
feeble  pulse ;  irregular  and  confused  beating  of  the  heart,  and 
cardiac  sounds  enfeebled  or  lost  over  the  right  side  of  the  organ  : 
rapidly-developed  distress  in  breathing,  referred,  by  the  sufferer, 
to  the  heartjt  and  signs  of  asphyxia,  though  all  the  time  the  patient 
is  taking  deep  inspirations ;  great  agitation ;  and  a  swollen  state 
of  the  veins  of  the  body.  Death  may  then  take  place  suddenly  if 
a  portion  of  the  clot  separate  and  obstruct  the  pulmonary  artery. | 

But  the  mode  of  death,  and  the  symptoms  preceding  it,  in 
embolism  of  the  pulmonary  artery,  are  not  always  the  same, 
and  depend  much  upon  the  size  of  the  embolus  and  where  it  is 
arrested.  A  large-sized  clot,  whether  it  be  merely  part  of  one 
occupying  the  right  heart,  or  be  Avashed  at  once  into  the  pulmo- 

*  Tuckwell,  St.  Bartholomew's  Hospital  Reports,  vol.  x.,  1874. 

f  B.  W.  Eichardson,  Medical  Times  and  Gazette,  Nov.  1808. 

X  As  in  a  case  recorded  by  Druitt,  Med.  Times  and  Gaz.,  .July,  1862. 


DISEASES   OF   THE   BLOOD.  797 

nary  artery,  will  occasion  the  same  signs  as  those  mentioned  as  in- 
dicative of  a  large  clot  in  the  right  side  of  the  heart;  the  craving 
for  air  is  particularly  intense,  and  this  craving  is  increased  by 
every  movement  of  the  body  ;  the  muscular  debility,  the  lowered 
temperature,  the  cyanosed  look,  the  turgid  veins  of  the  nectk  and 
their  undulations,  the  increased,  irregular  cardiac  impulse,  though 
the  heart's  action  is  not  sufficiently  deranged  to  account  for  the 
disturbed  respiration  and  disordered  general  circulation,  are  also 
noticed  ;  and  in  some  cases  a  systolic  blowing  sound,  and,  where 
the  case  is  at  all  protracted,  vertigo,  albuminuria,  and  oedema  of 
the  limbs,  may  be  observable.  The  intellect  remains  clear.  As 
regards  the  pulmonary  phenomena  proper,  collapse  of  the  lung, 
hemorrhagic  eifusions  or  so-called  infarctations,  oedema,  or  capil- 
lary  bronchitis  are  likely  to  happen,  except  in  those  instances  in 
which  the  principal  trunks  of  the  pulmonary  artery  are  blocked 
up  and  almost  instantaneously  asphyxia  ensues.  If  the  fragments 
be  very  small,  the  amount  of  dyspnoea  is  not  of  necessity  great, 
nor  are  the  symptoms  of  asphyxia  marked  ;  and  inflammations 
of  the  parenchyma  of  the  lungs  may  take  place,  occasioning  often 
secondary  obstructions  and  metastatic  abscesses  in  the  lungs.  These 
forms  of  metastatic  abscesses  are  observed  in  pyaemia,  and  are  not 
unusual  in  puerperal  fever. 

Blood  coagulates  in  the  arteries  as  a  consequence  chiefly  of  gan- 
grene and  of  ulceration.  Again,  inflammation  or  atheromatous 
disease  of  the  coats  of  the  arteries  may  lead  to  the  development 
of  thrombi ;  so  may  feeble  action  of  the  heart  and  increased 
coagulability  of  the  blood.* 

Still,  the  most  important  phenomena  connected  with  obstruction 
of  arteries  are  those  of  coagula  being  washed  into  them  ;  the  phe- 
nomena of  embolism,  therefore,  rather  than  those  of  thrombosis. 
The  manifestations  of  embolism  are  distinguished  from  those  of 
the  mere  formation  of  clots  by  what  is  always  the  most  significant 
sign  of  either  arterial  or  venous  embolism, — the  suddenness  of  the 
manifestation  of  the  abnormal  state.  And  in  point  of  fact  the 
symptoms  arise  less  often  as  the  result  of  any  of  the  conditions 
alluded  to  that  occasion  coagulation,  than  in  consequence  of  de- 
posits, fibrinous  concretions,  and  excrescences  which  are  seated  on 

«■  Liddell,  Amer.  Journ.  Med.  Sci.,  July,  1873. 


798  MEDICAL   DIAGNOSIS. 

the  valves  of  the  left  side  of  the  heart,  portions  of  which  deposits 
are  carried  away  by  the  circulating'  blood  into  remote  parts.  When 
these  bodies  become  impacted  in  a  vessel  the  calibre  of  which  is 
such  that  it  docs  not  permit  them  to  pass  on,  we  find  rapid 
changes  taking  place  in  the  portions  of  the  body  supplied  by  the 
obstructed  artery,  —  coldness,  ])allor  of  the  parts,  a  diminished 
functional  activity,  a  slirinking  ;  and  if  the  first  obstruction  be 
followed  by  others,  and  the  collateral  circulation  cannot  be  estab- 
lished, local  death  and  gangrene  ensue* 

All  these  changes  are,  of  course,  discernible  only  in  external 
parts,  especially  in  the  extremities ;  the  disturbances  of  function 
are  the  most  obvious  signs  where  the  internal  organs  are  the  suf- 
ferers. If  the  emboli  be  driven  to  the  brain,  we  have,  as  has 
been  already  mentioned,  softening  as  the  result,  and  this  may  be 
preceded  by  disorder  of  intellect,  without  motor  disturbances,  and 
by  severe  attacks  of  vertigo,  in  cases  in  which  merely  the  smaller 
arteries  supplying  the  surface  of  the  cerebral  hemispheres  are 
obstructed.  But  Avhere,  as  is  indeed  the  most  common  seat  of 
emboli,  the  arteries  of  the  fissure  of  Sylvius  are  clogged,  the  phe- 
nomena are  those  of  apoplectic  hemiplegia,  and  the  palsy  affects 
the  whole  of  one  side  of  the  body.  The  brain  may  also  suffer 
from  the  seat  of  the  obstruction  being  in  the  carotids ;  indeed,  of 
all  organs  the  effects  of  embolism  are  most  plainly  pcrce[)til)l(>  in 
the  brain.  The  presence  of  emboli  in  the  splenic,  renal,  hepatic, 
and  mesenteric  arteries  is  generally  only  to  be  inferred  from  the 
history  of  the  case,  and  does  not  occasion  any  clearly-discernible 
signs.  But  tenderness,  enlargement  of  the  spleen,  and  pain  in 
the  splenic  region  in  splenic  embolism,  or  disordered  secretion  of 
urine  and  pain  in  the  loins  in  embolism  of  the  renal  artery,  or 
jaundice  in  embolism  of  the  vessels  of  the  liver,  may  be  very  marked. 

The  occurrence  of  pain  in  these  cases  of  internal  embolism 
must  not  be  overlooked ;  and  in  embolism  of  the  arteries  of  the 
extremities  pain  is  a  sym})tom  of  still  greater  prominence.  It 
may  be  like  a  violent  neuralgia,  or  so  constant  that  it  is  mistaken 
for  rheumatism;  and,  as  happened  in  a  case  of  embolism  of  the 
right  iliac  artery,  under  the  charge  of  Dr.  James  H.  Tlutchin- 


*  As  regards  the  anatomical  lesions,  see  Litten,  Zeitschr.  f.  Klin.  Med.,  1880; 
and  Cohnheim,  Allg.  Path.,  2d  edit.,  Berlin,  1882. 


DISEASES   OF   THE   ELOOD.  790 

son,*  which  I  saw,  it  may  recur  in  paroxysms  of  intense  severity, 
and  be  referred  to  the  foot,  though  this  be  ah-eady  in  a  condition  of 
sphacelus.  Besides  the  pain,  we  are  apt  to  find  extreme  hyperses- 
thesia  in  some  parts  of  the  affected  limb;  and  pricking  sensations, 
formication,  ajid  loss  of  tactile  sense,  followed  by  comj)lete  anes- 
thesia, in  others.  Then  painful  spasms  of  the  muscles,  and  a 
more  or  less  perfect  paralysis  of  motion,  may  occur.  If  ^ve  join 
to  these  symptoms  an  absence  of  pulsation  in  the  arteries  Ijelow 
the  occlusion  until  the  collateral  circulation  is  decidedly  estab- 
lished, a  strong  beat  of  the  vessel  on  the  cardiac  side  of  the  ob- 
struction, the  coldness  of  the  limb  below  this  obstruction,  and  the 
signs  of  defective  supply  of  blood,  we  have  a  group  of  phenomena 
which,  taken  in  connection  wnth  the  history  of  the  case,  render 
the  diagnosis  a  positive  one.  In  reviewing  the  history  of  the  case 
the  state  of  the  heart  and  the  cardiac  symptoms  must  alwavs  be 
carefully  examined  into ;  and  a  close  inquiry  often  shows  that  the 
sudden  manifestations  of  arterial  obstruction  were  preceded  by  an 
attack  of  palpitation  and  of  irregular  action  of  the  heart. 

A  change  in  the  physical  signs  of  the  diseased  organ,  as  of  its 
murmurs,  may  not  be  evident;  but,  should  it  be  evident,  it  is  a  sign 
of  utmost  moment.  Indeed,  any  change  in  what  may  be  viewed 
as  the  centre  from  which  the  embolus  may  be  detached  is  of  great 
significance.  And  this  holds  good  quite  as  much  for  venous  as  for 
arterial  emboli.  Thus,  in  a  case  of  coagulum  in  a  vein,  a  sudden 
disappearing  of  swelling  and  oedema  of  the  affected  limb,  with  the 
supervention  of  signs  of  embarrassed  circulation  and  respiration, 
would  at  once  tell  what  had  taken  place. 

In  regard  also  to  the  diagnosis  of  embolism  we  must  alwavs 
bear  in  mmd  the  causes  which  are  likely  to  give  rise  to  it.  Several 
of  the  causes  of  arterial  embolism  have  already  been  mentioned ; 
those  of  venous  embolism  are  the  same  as  of  venous  thrombosis, 
or,  to  speak  more  explicitly,  the  breaking  up  of  the  clots  and  their 
transportation  may  occur  in  any  of  the  conditions  which  have  oc- 
casioned them.  Now,  these  conditions,  too,  will  produce  arterial 
clots,  and  indeed  some  are  more  apt  to  lead  to  coagulation  in  the 
arteries  than  in  the  veins.  Prominent  among  them  are  a  narrow- 
ing of  the  calibre  of  the  vessel,  as  by  pressure ;  dilatation  of  the 

*  Amer.  Journ.  Med.  Sci.,  Oct.  1863. 


800  MEDICAL   DIAGNOSIS. 

vessels  and  of  the  heart ;  f'aihire  or  great  diminution  of  cardiac 
power,  with  consequent  retardation  of  the  blood-stream, — a  state 
M'hii-h  is  more  likely  to  occasion  venous  than  arterial  thrombosis; 
a  breakage  in  the  continuity  of  the  vessel,  as  when  it  is  torn  or  cut; 
changes  which  take  place  in  the  coats  of  the  vessels,  especially  in- 
flammatory changes  ;  and  contact  of  the  blood  within  the  vessels 
with  foreign  bodies.  Then  it  is  very  likely  that  special  states  of 
the  blood  also,  by  altering  the  cohesion  of  the  globules,  predispose 
to,  if  they  do  not  absolutely  cause,  the  clotting. 

Another  cause  of  embolism  is  that  due  to  accumulations  of  pig- 
ment in  the  blood,  the  result  of  malarial  fever.  The  pigment  may 
obstruct  the  capillaries  in  the  brain  and  thus  occasion  capillary 
apoplexies;  ov  be  driven  to  the  liver  and  there  produce  signs  of 
disturbance  of  its  cireulaticm,  and  abscesses.  As  in  all  forms  of 
capillary  embolism,  the  symptoms  are  obscure :  the  suddenness  of 
their  development,  generally  so  characteristic  of  the  other  forms 
of  embolism,  is  wanting  ;  and  the  diagnosis,  as  throughout  in  capil- 
lary embolia,  is  always  nothing  more  than  a  matter  of  conject- 
ure, based  on  a  close  study  of  the  general  phenomena,  including 
the  microscopic  examination  of  the  blood,  and  on  tlie  history  of 
the  case.  Similar  symptoms  occurring  after  fractures  of  bone 
point  to  emboli  derived  from  the  marrow,  to  fat  embolism. 

Acute  endarteritis  may  be  the  cause  of  embolism  as  well  as  of 
pyemia.  Air  in  the  blood  produces  great  disturbance  of  the  cir- 
culation, which  may  be  thought  to  be  due  to  embolism.  The 
air  may  be  the  result  of  decomposition,  and  get  into  the  venous 
system  and  thence  into  the  general  circulation.  Jurgensen  *  has 
reported  a  case  in  whicli  tlie  air  passed  into  the  circulation  through 
the  splenic  vein.  Irregular  contraction  of  the  heart,  pallor  of  the 
face,  a  peculiar  systolic  cardiac  murmur,  faintness  and  the  signs  of 
cerebral  antemia,  and  slow  breathing,  are  the  common  symptoms. 

In  conclusion,  the  subsequent  changes  of  the  thrombus  must  be 
adverted  to.  It  may  organize  and  be  converted  into  connective 
tissue  and  yield  an  impaired  passage  to  the  blood ;  and  perliaps 
the  collateral  circulation  may  be  freely  established ;  or,  what  is  not 
so  favorable  a  result,  it  may  soften  and  undergo  fatty  metamor- 
phosis.   But  even  when  larger  portions  are  not  detached  and  occa- 

*  Archiv  f.  Klin.  Med.,  Bd.  xxii.,  1882. 


DISEASES   OF   THE   BLOOD.  801 

sion  the  marked  symptoms  of  embolism,  small  ones  may  be  wafted 
into  capillaries  and  there  lay  the  foundation  of  abscesses.  It  is  thus 
that  in  a  case  of  thrombus  or  embolus  we  may  have  the  second- 
ary results  of  pysemia  to  deal  with, — metastatic  abscesses  caused 
in  the  manner  described,  and  attended  with  a  blood  profoundly 
altered  and  vitiated  by  the  decomposing  products  circulating  in  it. 

Scurvy. — This  disease  is  not  often  met  with  in  civil  practice; 
but  it  is  one  familiar  to  the  military  and  the  naval  surgeon.  It 
consists  in  a  deterioration  of  the  blood,  produced  by  living  for  a 
long  period  upon  the  same  kind  of  food,  and  especially  upon  salted 
meats,  without  the  requisite  supply  of  fresh  vegetables  being  taken. 
Now,  the  potent  influence  of  vegetables  is  attributed  to  the  large 
quantity  of  potassium  they  contain  ;  and,  as  there  is  a  deficiency 
of  the  salts  of  potassium  in  scorbutic  blood,  it  was  concluded  that 
this  deficiency  is  the  real  cause  of  scurvy.  But  this  theory  has 
not  been  positively  proved.  Another  cause  of  scurvy  is  the  want 
of  proper  assimilation  of  food,  as  in  prison  scurvy.* 

Scurvy  is  usually  slow  in  its  development.  The  patient  be- 
comes low-spirited,  easily  fatigued,  and  is  loath  to  exert  himself. 
The  appetite  is  impaired ;  there  is  a  craving  for  acids  and  for 
vegetable  food  ;  the  tongue  is  flabby  ;  the  breath  fetid  ;  the  pulse 
feeble  ;  the  skin  dry.  The  bowels  are  usually  constipated ;  but  a 
tendency  to  diarrhoea  may  exist,  and  indeed  generally  occurs  as  the 
disease  advances.  Neuralgic  pains,  referred  chiefly  to  the  lower 
extremities,  to  the  bones,  and  to  the  back  or  thorax,  are  common. 
The  face  is  pale,  or  has  a  yellowish  tinge  ;  the  eyes  are  surrounded 
by  a  dark  ring.  During  the  progress  of  the  ailment,  or  in  severe 
cases  almost  from  the  onset,  we  find  swollen,  spongy  gums,  bleed- 
ing on  the  slightest  touch ;  hurried  breathing ;  a  rapid  pulse ; 
weakened  eyesight,  sometimes  night-blindness ;  epistaxis  ;  painful 
swelling  and  hardness  about  the  joints  of  the  extremities  and  in 
the  calves  of  the  legs ;  and  purple  spots  and  bruise-like  stains  on 
the  skin.  Should  the  malady  remain  unchecked,  the  symptoms 
heighten  in  severity,  ulcers  form  which  have  a  fungoid  look  and 
a  great  tendency  to  bleed,  hemorrhages  take  place  from  internal 
organs,  old  sores  and  wounds  reopen,  well-knit  fractures  become 
disunited,  there  is  a  constant  tendency  to  swoon,  and  the  patient 


See  Medical  Memoirs  of  the  U.  S.  Sanitary  Commission,  p.  278, 
51 


802  MEDICAL   DIAGNOSIS. 

perishes  miserably  exhausted,  and  with  his  blood  in  a  state  of 
dissolution.  Scurvy  may  be  the  cause  of  epidemics  of  })ericar- 
ditis.*  In  some  cases  death  takes  place  from  diarrhoea  or  dropsy, 
which  may  be  suddenly  developed.    Recovery  from  scurvy  is  slow. 

Purpura. — Scurvy  is  not  a  disease  difficult  to  recoiiuize ;  only 
one  affection  resembles  it  at  all  closely, — ■purpuni.  In  this  dis- 
order also  red  or  j^urple  S])ots  or  livid  blotches,  uninfluenced  by 
pressure,  and  passive  hemorrhages  from  the  mucous  membranes, 
happen.  But  there  is  this  difference  between  the  two  complaints  : 
purpura  is  connnon  in  fruit  seasons,  and  often  attacks  persons  who 
have  not  been  in  any  way  deprived  of  vegetable  food.  The  gums 
are  not  soft  and  spongy  as  in  scurvy,  nor  do  we  find  the  same  weak- 
ness of  mind  and  body.  Then,  the  stain  of  the  skin  in  purpura 
is  apt  to  be  more  generally  diffused,  and  the  purple  blotches  are 
smaller,  or,  at  all  events,  the  large  patches  of  discoloration  consist 
clearly  of  an  aggregation  of  very  many  small  spots.  IMoreover, 
the  disorder  is  not  controlled,  like  scurvy,  by  fresh  vegetables,  and 
by  lemon-juice, — in  fact,  by  decided  antiscorbutics. 

From  a  clinical  point  of  view  we  find  several  forms  of  purpura. 
In  the  mildest,  the  purpurous  spots  are  apt  to  appear  only  on  the 
legs.  They  come  in  crops,  which  fade,  and  there  are  no  constitu- 
tional symptoms,  except  a  little  lassitude,  and  perhaps  aching  of 
the  limbs  and  pain  in  the  back.  In  the  graver  cases,  "  purpura 
hoeraorrhagica,"  we  find,  in  addition  to  the  cutaneous  hemorrhage, 
epistaxis,  haematemesis,  hematuria,  or  other  internal  hemorrhages, 
and  extravasations  of  blood  may  happen  into  the  substance  of  the 
muscles.  The  amount  of  pain  attending  the  malady  is  very  dif- 
ferent. There  may  be  none,  or  it  may  be  trifling ;  or  deep-seated 
pains  in  the  cavities  of  the  body,  or  extended  neuralgic  pains,  may 
accompany  the  purpurous  complaint.  In  some  instances  the  pains 
are  chiefly  felt  in  and  around  the  joints,  and  the  apparently  rheu- 
matic aches  subside  in  a  few  days,  and  spots  of  extra vasated  blood 
become  visible.  This  "  purpura  rheumatica,"  a  variety  particu- 
larly described  by  Schonlein,  is  usually  met  with  in  the  strong 
and  healthy.  It  is,  indeed,  one  of  the  peculiarities  of  any  kind  of 
purpura,  that  it  may  come  on  in  the  midst  of  seemingly  excellent 
health  ;  for  while  it  is  true  that  the  disorder  may  be  ]>receded  for 

*  Von  Dusch,  Herzkrankheiten. 


DISEASES    OF    THE    BLOOD.  803 

some  time  by  signs  of  general  debility,  or  occur  in  the  com'se  of 
disease  of  the  liver,  of  Bright's  disease,  or  as  a  sequel  to  the  exan- 
themata and  rheumatic  fever,  it  most  often  happens  where,  from 
previous  looks,  we  should  least  expect  it.  Its  production  as  the 
result  of  a  sudden  shock  to  the  nervous  system,  such  as  fright,  and 
its  occasional  intermittent  character,  have  been  repeatedly  noticed. 

The  duration  of  the  malady  is  very  variable :  only  a  week  may 
elapse,  or  several  months  may  pass,  before  the  spots  disappear. 
Its  pathology  is  unknown.  It  is  clearly,  however,  not  merely  a 
disease  of  the  blood ;  the  capillaries  lose  their  retentiveness  and 
allow  the  corpuscles  to  migrate.  In  some  cases  purpura  presents 
an  acute  form.  It  is  ushered  in  by  a  chill,  and  by  intense  pain 
in  the  back  and  limbs,  but  is  generally  unattended  with  fever  or 
severe  constitutional  disturbance.  The  purple  spots  usually  first 
appear  on  the  legs,  and  are  wholly  uninfluenced  by  pressure. 
They  last  five  or  six  days,  or  somewhat  longer,  then  gradually 
change  their  color  and  fade.  The  patient  feels  languid,  but, 
unless  from  loss  of  blood,  his  strength  is  not  materiallv  im- 
paired. The  effusion  of  blood  happens  in  some  cases  into  the 
loose  connective  tissues  of  the  body,  or  blood  is  lost  from  the 
lungs,  and  still  more  frequently  from  the  bowels  or  the  urinary 
organs.  Under  these  circumstances  the  pulse,  which  is  apt  to 
preserve  its  normal  frequency,  becomes  very  rapid ;  but  until  ex- 
haustion begins  to  tell  on  the  nervous  system — not,  as  a  rule,  long 
before  dissolution — the  mind  remains  clear,  and  cerebral  or  spinal 
symptoms  are  absent.  It  is  thus  that  we  are  able  to  distinguish 
severe  cases  of  acute  purpura,  which  may  indeed  prove  fatal  in 
forty-eight  hours,*  from  cerebro-spinal  meningitis. 

The  distinction  between  hsemopMUa  and  purpura  is  generally 
simple.  It  is  true  that  the  bleeding  in  a  member  of  a  bleeder's 
family  may  happen  into  the  skin  or  from  any  of  the  parts  from 
which  it  may  take  place  in  purpura ;  but  the  family  history,  the 
congenital  proneness  to  frequent  hemorrhages  from  the  slightest 
cause,  their  danger  and  protraction,  the  functional  excitement  of 
the  heart,  followed  perhaps  even  by  cardiac  hypertrophy,  the  close 
relationship  to  rheumatic  aifections,  and  the  hemorrhagic  diathesis 
exhibited  in  haemophilia,  stamp  this  with  distinctive  features. 

*  Harrison  Allen,  Amer.  Journ.  Med.  Sci..  Jan.  1865. 


CHAPTER    XI. 

RHEUMATISM   AND   GOUT. 

Rheumatism  and  Gout  are  affections  having  a  strong  ten- 
dency to  change  their  scat,  and  are  dependent  upon  the  presence  in 
the  blood  of  some  poisonous  material  which  probably  accumulates 
there  in  consequence  of  malassimilation.  The  rheumatic  poison 
has  a  singular  predilection  for  the  fibrous,  serous,  and  muscular 
textures.  Hence  we  find  it  attacking  principally  the  joints,  the 
fascire,  the  endocardium  and  pericardium,  and  the  muscles  in 
various  parts  of  the  body.  According  to  its  main  forms,  it  is 
sometimes  divided  into  articular  and  muscular ;  but  the  more 
usual  division  into  acute  and  chronic  is  simpler,  and  will  answer 
our  purpose  best. 

Acute  Rheumatism.  —  Here  the  poison  gives  rise  to  the 
symptoms  of  an  acute,  active  disease,  and  attacks  especially  the 
larger  joints.  These  swell,  become  hot,  red,  tense,  tender,  and  the 
seat  of  pain  aggravated  by  the  slightest  movement ;  an  effusion 
also  takes  place  into  the  surrounding  structures,  or  into  them  and 
the  synovial  membranes  of  the  joint  itself.  The  rheumatic  inflam- 
mation may  either  remain  confined  to  the  joints  first  affected  until 
the  disease  is  over,  or,  what  is  more  common,  it  shifts  from  joint 
to  joint,  implicating  most  of  the  large  ones  in  succession,  yet  often 
invading  fresh  joints  before  the  swelling  has  subsided  in  the  parts 
first  attacked.  The  articular  disorder  is  ushered  in  and  accom- 
panied by  high  fever,  soon  attended  with  a  full,  bounding  pulse, 
profuse,  sour  perspirations,  a  deeply-coated  tongue,  a  scanty, 
turbid,  highly-acid  urine,  and  a  countenance  expressive  of  suffer- 
ing. The  fever  is  generally  in  proportion  to  the  number  of  joints 
involved.  The  temperature  runs  up  to  about  102°  or  103°  Fahr. 
very  soon  after  the  outbreak  of  the  malady,  and  remains  steady, 
with  slight  evening  exacerbations  and  morning  remissions  when 
the  joint-affection  is  yielding,  but  with  renewed  rises  when  fresh 
804 


EHEUMATISM   AND   GOUT.  805 

joints  are  being  implicated.  As  the  disease  disappears,  the  fever 
temperature  gradually  subsides. 

There  is  little  difficulty  in  recognizing  the  complaint.  The 
pains  in  the  joints,  their  tumefaction  and  tenderness,  the  shifting 
character  of  the  disorder,  the  fever,  the  acid  sweats,  form  a  group 
of  phenomena  eminently  characteristic.  In  truth,  excluding  acute 
gout,  the  only  affections  at  all  likely  to  be  confounded  with  acute 
articular  rheumatism  are  pysemia  and  glanders,  acute  synovitis, 
and  milk-leg.  The  diagnosis  of  the  former  has  been  discussed  in 
connection  with  diseases  of  the  blood ;  it  only  remains  to  point 
out  the  marks  of  similitude  and  contrast  between  acute  articular 
rheumatism  and  the  other  maladies  mentioned. 

Acute  synovitis  resulting  from  an  injury,  or  from  cold,  occasions, 
like  articular  rheumatism,  pain  and  heat  in  the  joint,  with  disten- 
tion. But  the  disorder,  except,  perhaps,  if  it  happen  in  a  rheu- 
matic constitution,  does  not  affect  more  than  one  joint;  and,  as 
there  is  scarcely  any  or  no  effusion  into  the  surrounding  tissues, 
the  outline  of  the  joint  can  be  distinctly  discerned,  and  fluctuation 
is  readily  detected.  Often,  too,  the  accumulation  of  fluid  reaches 
an  extent  far  greater  than  in  rheumatic  inflammation ;  moreover, 
the  febrile  and  constitutional  derangement  is  not  so  severe  as  in 
acute  rheumatism,  and  the  affection  has  no  tendency  to  change 
its  seati     Still,  acute  synovitis  may  be  rheumatic* 

Milk-leg,  or  phlegmasia  alba  dolens,  occurs  most  usually  in 
women  after  delivery,  or  as  a  sequel  of  continued  fevers.  Gener- 
ally, only  one  leg  swells,  and  this  becomes  throughout,  or  some- 
times only  around  the  calf,  preternaturally  white,  firm,  hot,  and 
shining.  The  tumefaction  is  uniform,  and  very  painful,  especially 
so  when  touched.  It  does  not  pit,  or  pits  but  slightly,  upon  press- 
ure, except  at  the  lower  part.  There  is  in  some  cases  tenderness 
with  a  sense  of  hardness  in  the  course  of  the  femoral  vein,  though 
this  is  by  no  means  constant;  and  we  are  apt  to  find  signs  of  much 
debility  and  of  altered  blood,  and  febrile  symptoms.  But  the 
history  of  the  case  and  the  local  signs  are  dissimilar.  Among 
the  latter,  two  giving  rise  to  striking  differences  may  be  men- 
tioned :  the  almost  entire  loss  of  power  in  the  affected  limb  in 
phlegmasia   alba  dolens,  and   the   much   higher   temperature  it 

*  See  Adams,  Medical  Times  and  Gazette,  Feb.  1869. 


806  MEDICAL    DIAGNOSIS. 

shows  bv  the  thermometer  than  the  other  members.  And,  while 
alluding  to  its  heat,  we  may  remark  that  an  inerease  of  general 
temperature  corresponds  to  an  inerease  of  pain  and  swelling  in 
the  limb,  and  of  eonstitutional  distress.*  Phlegmasia  dolens  has 
been  noted  in  assoeiation  with  ehlorosis.f 

Rheumatism  may  be  modified  in  its  manifestations  by  happen- 
ing in  conneetion  with,  or  conse([uent  u])on,  other  disorders.  For 
instance,  the  febrile  phenomena  may  be  of  an  adynamic  type  when 
the  disease  occurs  consecutively  to  typhoid  or  typhus  fever ;  or  we 
may  find  the  local  signs  of  acute  rheumatism  strangely  mixed  with 
the  symptoms  of  puerperal  fever,  and  in  some  of  these  eases  pus 
may  fill  the  tumid  joints ;  or  the  presence  of  the  syphilitic  poison 
or  of  gonorrhoea  may  imprint  peculiar  features  upon  the  com- 
plaint ;  and  in  most  of  the  instances  mentioned  the  rheumatism 
is  probably  of  different  blood-origin. 

In  gonorrhoeal  rheumatism  there  is  usually  less  febrile  distress ; 
the  articular  pain  is  not  so  severe  or  acute ;  the  integument  cover- 
ing the  affected  joint  is  apt  to  retain  its  normal  color ;  there  may 
be  but  one  joint — and  there  are  not  generally  many — implicated; 
the  inflammation  is  confined  to  the  synovial  membrane,  and  a 
copious  sero-fibrinous  exudation  occurs;  the  joint-aifection,  which 
is  pre-eminently  an  affection  of  one  knee,  shows  a  tendency  to 
shift,  and  resembles  rather  an  acute  or  a  subacute  rheumatoid  ar- 
thritis than  acute  rheumatism ;  the  eye,  too,  unlike  what  happens 
in  ordinary  acute  rheumatic  fever,  is  often  attacked.  There  is  no 
copious  sweating,  and  no  disturbance  of  the  heart ;  and  often  there 
has  been  a  running  from  the  urethra,  which  diminishes  when  the 
gonorrhoeal  rheumatism  sets  in,  but  which  does  not  cease.  The 
disorder  does  not  come  on  early  in  a  case  of  gonorrhoea ;  and  the 
joint-affection  appears  really  to  be  of  pyjemic  origin.  It  disap- 
pears only  very  slowly,  and  is  uninfluenced  by  salicylic  acid.|  It 
is  by  all  these  signs  that  we  judge  of  the  malady  with  much  more 
certainty  than  by  the  mere  presence  of  gonorrhoea  with  the  symp- 
toms of  rheumatism,  for  the  former  may  be  a  mere  coincidence. 
Gonorrhoeal  rheumatism  may  run  an  acute  course.§ 


*  Elliott  Richardson,  Pennsylvania  Hospital  Reports,  vol.  ii. 

t  Perret,  Lyon  Medical,  1888.  %  Gt-rnian  edition  of  this  work. 

§  Davies-Colley,  Guy's  Hospital  Reports,  1883. 


RHEUMATISM    AND   GOUT.  807 

The  traits  of  an  attack  of  acute  rheumatism  are  frequently 
altered  by  certain  complications  in  internal  organs  which  the  con- 
taminated blood  is  apt  to  occasion.  Prominent  among  them  are 
the  cardiac  disorders,  which  are  in  fact  so  common  that  they  may 
be  looked  upon  as  forming  part  of  the  rheumatic  manifestation 
rather  than  as  being  one  of  its  complications;  their  signs  we  have 
investigated  already,  while  examining  endocarditis  and  pericar- 
ditis. Certain  cardiac  plienomena,  such  as  extreme  pain  without 
evidence  of  recent  valvular  affection,  pain  which  may  shoot  to 
the  neck  and  shoulder  and  be  associated  with  signs  of  great  irri- 
tability of  the  heart  or  of  heart-failure,  have  been  by  some  ob- 
servers, as  by  Peter  and  Letulle,*  attributed  either  to  rheumatic 
myocarditis,  or  to  an  abnormal  excitement  of  the  cardiac  plexus, 
of  rheumatic  origin. 

Other  complications  are  inflammations  of  the  lung,  particu- 
larly of  the  bronchial  tubes  and  of  the  pleura ;  an  affection  of 
the  kidney  which  is  generally  a  parenchymatous  nephritis  with 
some  albumen  and  tube-casts,  but  which  may  be  due  to  pysemic 
or  embolic  infarction  ;f  and  —  though  not  often — cerebro-spinal 
disturbances,  exhibiting  themselves  by  headache,  violent  delirium, 
convulsions,  and  coma,  and  occurring  either  in  connection  with  a 
thoracic  disorder,  or  solely  in  consequence  of  the  action  of  the 
vitiated  blood  on  the  nervous  centres,  or  in  consequence  of 
Bright's  disease  or  of  multiple  capillary  embolism,  or  of  the 
sudden  exhaustion  of  the  nervous  centres.  This  explanation! 
has  been  more  particularly  applied  to  the  cases  in  which  an  ex- 
cessive temperature  attends  the  rapidly-developed  signs  of  cere- 
bral disturbance,  a  temperature  of  107°  or  more.  But,  speaking 
from  a  bedside  point  of  view,  we  must  remember  that  such  cases 
are  comparatively  rare,  and  that  rheumatic  delirium  is  far  from 
always  of  the  same  nature.  It  may  be  of  the  kind  just  men- 
tioned. It  may  develop  itself  with  or  without  the  signs  of  cardiac 
complaint.  It  may  come  on  early  in  the  disorder  during  the 
violence  of  the  fever ;  or  late,  and  clearly  from  debility  and  im- 
poverished blood,  yielding  to  nourishment  and  stimulants.     It  is 

*  Archives  Generales  de  Medecine,  June,  1880. 

f  Chomel,  Kecherches  sur  les  Keins  dans  le  Ehumatisme,  Paris,  1868 ;  also 
_Schmidt's  Jahrb.,  No.  2,  1871. 

f  "Weber,  Transactions  of  the  Clinical  Society  of  London,  vol.  i. 


808  MEDICAL    DIAGNOSIS. 

rarely  the  result  of  meningitis.  Tlie  delirinni  whicli  attends  cere- 
bral rheumatism  may  be  marked  by  great  talkativeness,  or,  on  the 
other  hand,  the  patient  may  be  extremely  taciturn.*  Insanity 
may  follow  the  brain  symptoms  of  acute  rheumatism. 

The  occurrence  of  nodules  in  connection  with  rheumatism, 
especially  among  children,  has  attracted  a  good  deal  of  atten- 
tion. They  are  met  with  chiefly  in  the  neighborhood  of  joints, 
especially  of  the  elbow.  These  fibrous  nodules  may  appear  at 
once  in  any  form  of  rheumatism,  or  come  out  in  crops.  They 
are  not  tender.  They  most  often  occur  in  cases  of  rheumatic 
endocarditis  or  pericarditis. 

In  a  few  instances  of  rheumatism  we  find  acute  arteritis  arising, 
and  especially  inflammation  of  the  fibrous  structures  of  the  aorta. 
This  condition  may  be  suspected  should  we  observe  intense  gen- 
eral uneasiness  and  distress,  with  pain,  increased  pulsation,  a  dis- 
tinct murmur  in  the  course  of  the  vessel,  and  tumultuous  action 
of  the  heart  without  there  being  obvious  signs  of  disease  of  that 
organ  present.     Still,  the  diagnosis  is  never  a  positive  one. 

Acute  rheumatism  rarely  ends  fatally ;  its  cardiac  consequences 
are  more  to  be  feared  than  the  acute  attack.  Cases  occur  not  unfre- 
quently  in  which  the  inflammation  in  the  joints  is  lingering,  and 
in  which  the  febrile  symptoms  are  not  intense.  These  cases  form 
an  intermediate  grade  between  acute  and  chronic  rheumatism,  and 
are  spoken  of  as  subacute.  The  disorder  is  more  apt  than  the 
acute  N^ariety  to  affect  the  muscles  as  well  as  the  joints ;  nay,  the 
former  may  be  alone  attacked.  It  may  be  witnessed  in  the 
joints  of  one  extremity,  or  in  one  joint,  and  might  then  be  mis- 
taken for  synovitis.  But  the  dissimilar  history  of  the  complaint 
will  guard  against  error :  no  accident  has  happened  to  account 
for  the  swelling  of  the  joint,  and  often  the  patient  will  tell 
us  that  he  has  had  previously  an  attack  of  rheumatism.  The 
subacute  form  of  rheumatism  is  more  likely  to  be  confounded 
with  rheumatic  arthritis :  we  shall  presently  refer  to  their  dis- 
tinction. 

Chronic  Rheumatism. — This  may  either  be  a  sequel  of  the 
acute  disease,  or  the  disorder  may  from  the  onset  assume  a  linger- 

*  Some  of  these  points  are  more  fully  detailed  in  a  paper  on  Cerebral 
Rheumatism  published  in  the  Amer.  Journ.  Med.  Sci.,  Jan.  1875. 


RHEUMATIS^r    AND   GOUT.  809 

ing  form,  the  constitutional  symptoms  being  slight.  The  affection 
may  show  itself  in  the  joints,  giving  rise  to  stiffness,  dull  aching, 
pain  produced  by  motion,  but  without  heat  or  very  obvious  swell- 
ing, tenderness,  and  febrile  excitement,  or  marked  sweating ;  or  it 
may  implicate  the  muscles  in  various  parts  of  the  body,  occasion- 
ing stiffness,  as  well  as  pain  when  they  are  moved ;  or  it  may 
attack  both  joints  and  muscles ;  or  it  may  be  seated  chiefly  in  the 
sheaths  of  nerves,  leading  to  what  is  called  rheumatic  neuralgia, 
of  which  sciatica  often  affords  a  striking  example.  In  any  case 
the  occurrence  of  the  pain  furnishes  the  starting-point  in  diag- 
nosis ;  and  we  must  ascertain,  by  careful  examination,  whether 
it  be  augmented  by  motion,  whether  it  be  more  or  less  shifting, 
whether  it  be  not  combined  with  stiffness  either  of  the  muscles  or 
of  the  joints,  whether  it  be  influenced  by  changes  of  temperature, 
whether  it  be  not  neuralgic,  or  associated  with  a  disturbance  of 
some  viscus,  such  as  of  the  liver  or  kidneys,  before  we  conclude 
that  the  complaint  is  really  rheumatic. 

This  is  especially  necessary  in  the  most  common  form  of  chronic 
rheumatism,— muscular  rheumatism.  All  kinds  of  pains  in  the 
muscles  or  their  surroundings,  the  cause  of  which  is  not  at  once 
apparent,  are  apt  to  be  pronounced  rheumatic.  And  indeed  it  is 
not  always  easy  to  say  whether  they  are  or  are  not  of  that  char- 
acter. We  may  distinguish  them  from  the  anguish  of  neuralgia 
by  the  pain  in  the  latter  complaint  being  ordinarily  confined  to 
the  distribution  of  one  nerve  and  not  being  increased  by  movement 
or  by  pressure,  nor  is  it  so  steady,  or  attended  with  soreness, 
except  over  a  few  spots  at  some  distance  from  one  another  in  the 
course  of  the  affected  nerve. 

As  regards  the  pains  caused  by  organic  structural  disease,  we 
can  generally  discriminate  them  from  those  of  rheumatism  by 
close  attention  to  the  history  of  the  case,  and  by  a  careful  explora- 
tion of  the  internal  organs.  Thus,  for  instance,  we  shall  find  pain 
radiating  from  the  right  hypochondrium  to  the  shoulder  to  be 
dependent  upon  hepatic  disease ;  or  pain  shooting  down  to  the 
groin,  thigh,  and  testicle  to  be  caused  by  a  disturbance  of  the 
kidney ;  or  a  bearing  down  and  an  aching  near  the  sacrum  to  be 
probably  due  to  uterine  disorder. 

Muscular  rheumatism  may  affect  the  neck,  the  scalp,  the  mus- 
cles of  the  face,  and  the  parietes  of  the  chest  or  of  the  abdomen. 


810  MEDICAL    DIAGNOSIS. 

It  may  be  not  only  chronic  in  any  of  these  situations,  bnt  also 
acute ;  or,  Avhat  is  more  frequent,  when  it  occurs  witli  fever  and 
is  transient,  it  is  a  sudden  acute  exacerbation  in  persons  who  are 
rheumatic  and  suffer  more  or  less  persistently  from  rheumatism, 
though  perhaps  in  a  different  part  of  the  body  from  the  one  in 
w^hich  the  acute  affection  has  happened.  Muscular  rheumatism 
has  been  noticed  in  an  epidemic  form.* 

One  of  the  most  common  seats  of  muscular  rheumatism  is  in 
the  loins.  It  then  constitutes  tlie  disease  known  as  lumbago.  The 
l)atient  is  unable  to  stand  erect,  and  finds  it  nearly  impossible  to 
stoop  forward,  on  account  of  the  severe  pain  occasioned  when  the 
muscles  of  the  back  are  called  into  action.  Unless  the  attack  be 
very  severe  or  acute,  there  is  no  constitutional  disturbance ;  but 
the  disorder  is  often  obstinate.  It  is  easy  of  recognition.  We 
distinguish  it  from  pain  in  the  loins  due  to  disease  of  the  kid- 
neys, chiefly  by  an  examination  of  the  urine,  and  by  the  different 
way  in  which  movement  affects  the  rheumatic  pain;  from  lumbo- 
abdominal  neuralgia,  by  the  two  or  three  sore  spots  in  the  course 
of  the  affected  nerve ;  from  rheumatism  of  the  vertebral  articula- 
tions, by  the  absence  of  tenderness  and  swelling  around  the  spi- 
nous processes;  from  lumbar  abscess,  by  the  want  of  local  bulging 
or  fulness,  of  fluctuation,  and  of  fever.  Then,  we  must  be  careful 
not  to  consider  as  lumbago  the  pain  in  the  back  caused  by  disease 
of  the  spine,  or  by  disorder  of  the  uterus,  or  by  the  passage  of  ab- 
normal urinary  constituents,  such  as  oxalate  of  lime,  or  consequent 
upon  strains,  or  blows,  or  scurvy,  or  malaria,  or  ansemia,  or  a  gen- 
eral or  local  muscular  debility. 

Thus  there  are  many  causes  of  pain  in  the  loins,  and  where 
the  case  is  of  any  duration  or  of  any  doubt  we  must  be  careful 
to  exclude  these  causes  from  consideration  before  we  assume 
the  disease  to  be  really  rheumatism  of  the  muscles  and  fasciae 
of  the  back.  This  caution  is  very  necessary  in  investigating 
the  cases  of  "  weak  back"  so  prevalent  among  soldiers,  which, 
though  commonly  spoken  of  as  rheumatic,  are  really,  for  the  most 
part,  due  to  strains  or  injuries  which  have  perhaps  produced  a 
weakness  of  the  muscles  and  a  persistent  cutaneous  hyperaes- 
thesia;  or  to  an  impoverished  blood,  to  neuralgia,  to  scurvy;  or 

*  Schmidt's  Jahrb.,  No.  12,  1872. 


EHEUMATISM   AND  GOUT.  811 

to  digestive  disorders  attended  with  the  passage  from  the  kidneys 
of  large  amounts  of  urates  or  of  oxalate  of  lime. 

The  remarks  made  with  reference  to  this  form  of  muscular 
rheumatism  and  the  states  which  simulate  it  are  also  applicable  to 
pains  apparently  muscular  affecting  other  portions  of  the  body. 
We  may  have  pain  and  soreness  of  the  muscles  developed  by 
strain  or  overwork  and  attended  both  with  muscular  and  with 
cutaneous  hypersesthesia, — a  condition  very  different  from  rheu- 
matism, and  designated  by  Inman*  "myalgia."  This  soreness 
of  the  muscles  is  always  in  direct  proportion  to  their  debility,  and 
is  chiefly  caused  by  long-continued  exertion  beyond  the  power 
of  the  muscle,  or  by  an  ordinary  amount  of  action  when  it  or 
the  individual  himself  is  extremely  debilitated.  The  morbid  state 
is  most  marked  during  the  convalescence  from  scarlet  fever,  where 
it  may  be  looked  upon  as  due  to  over-exertion  of  the  weakened 
muscles.  The  soreness  of  the  muscle  is  almost  constantly  accom- 
panied by  heightened  sensibility  of  the  skin  over  it ;  and  this 
coexisting  cutaneous  tenderness  may  be  in  any  case  regarded  as 
an  important  diagnostic  sign.  Myalgia  is  chiefly  found  in  the 
muscles  of  the  trunk,  and  is  very  rarely  general. 

Another  form  of  muscular  rheumatism  which  we  may  here 
mention  is  wry-neck,  or  torticollis.  This  depends  chiefly  upon 
contraction  of  the  sterno-cleido-mastoid  muscle  of  one  side,  and 
occasions  the  ungainly  appearance  with  which  most  persons  are 
familiar.  But  we  must  be  careful  not  to  consider  every  case  as  of 
rheumatic  origin.  The  disorder  may  be  spastic,  or  may  depend 
upon  nervous  injury,  and  when  chronic  may  lead  to  alteration  in 
the  muscular  structure.  Injections  of  atropine,  hypodermically, 
may  generally  be  used,  not  only  for  their  good  therapeutic  effect, 
but  also  because,  even  in  chronic  cases,  they  may  show  us,  by  the 
difficulty  or  impossibility  of  relaxing  the  muscle,  how  much  of  it 
is  really  changed. 

Pain  in  the  muscles  and  stiffness  may  be  caused  by  still  other 
conditions  than  those  described,  and  be  mistaken  for  muscular 
rheumatism, — the  muscular  pains  of  trichiniasis.  But  the  marked 
exhaustion  and  the  signs  of  gastro-intestinal  catarrh  are  of  such 
significance  that  they  save  us  from  error. 

*  Spinal  Irritation  Explained,  or  a  Treatise  on  Myalgia. 


812  MEDICAL   DIAGNOSIS. 

A  form  of  chronic  rhcuniatisni  wliicli  also  may  be  briefly 
mentioned  is  that  atlecting  chiefly  the  iibrous  membranes,  such  as 
the  periosteum.  This  becomes  thick,  and  tender  on  pressure;  its 
thickening  may  eyen  be  yery  perceptible  to  the  touch  as  well  as  to 
the  eye.  This  kind  of  rheumatism  ha])pens  in  those  who  haye 
syphilis ;  but  it  also  occurs  where  no  such  taint  exists.  The  pains 
are  generally  much  more  severe  at  night ;  and  this  is  sometimes 
assumed  to  be  a  proof  of  the  syphilitic  character  of  t\\G  disease, 
— but  incorrectly  so  ;  for  many  varieties  of  chronic  rheumatism 
are  aggravated  by  the  warmth  of  bed.  Indeed,  the  only  really 
diagnostic  signs  of  syphilitic  rheumatism  are  the  obvious  evi- 
dences of  constitutional  syphilis,  or  the  history  of  the  infection. 
Still,  to  cases  in  which  several  nodes  exist,  and  in  which  the  pains 
more  j)articularly  affect  the  long  and  flat  bones,  and  in  which 
iodide  of  potassium  speedily  modifles  the  pains,  we  shall  be  rarely 
wrong  in  attributing  a  syphilitic  origin. 

Chronic  rheumatism  is  often  feigned,  especially  by  malingerers 
in  the  army  and  the  navy,  and  the  deception  may  be  difficult  of 
detection.  They  pretend  to  be  scarcely  able  to  walk,  or  hobble 
around  with  a  cane,  and  complain  much  of  the  pain  and  stiffness 
in  their  joints.  Yet  there  is  not  the  least  sign  of  deformity  or 
real  stiffness ;  the  pain  is  always  stated  to  be  the  same  ;  and  their 
general  health  is  excellent.  Their  way  of  using  the  stick,  too,  is 
characteristic :  they  move  it  each  time  they  move  the  seemingly 
crippled  leg,  but,  as  a  rule,  not  immediately,  thus  not  employing 
it  as  a  support.  Anaesthetics  are  of  great  value  in  enabling  us  to 
decide  as  to  the  real  amount  of  immovability  of  the  limb. 

Gout. — This  disease  may  be,  like  rheumatism,  either  acute  or 
chronic.  Instead  of  describing  its  phenomena,  I  shall  at  once 
point  out  the  marks  of  difference  between  the  two  kindred  mala- 
dies. In  gout,  the  small  joints  are  chiefly  or  alone  affected ;  in 
rheumatism,  the  large.  The  gouty  inflammation  is  accompanied 
by  more  local  pain  and  redness  than  the  rheumatic,  and  by  oedema, 
enlargement  of  the  veins,  and  desquamation  of  the  cuticle,  and 
implicates,  at  least  at  first,  only  one  or  a  few  joints,  especially  the 
joint  of  the  great  toe;  while  rheumatism  attacks  the  joints  of 
the  upper  as  well  as  of  the  lower  extremities.  In  gout  there  is 
a  tendency  to  disease  of  the  kidneys,  with  a  moderate  febrile  dis- 
turbance, and  no  profuse  sweats ;  but  we  meet  with  no  cardiac 


RHEUMATISM   AND   GOUT.  813 

complication,  at  least  no  valvular  aifection,  as  so  constantly  hap- 
pens in  rheumatism.  Gout  is  more  decidedly  hereditary  than 
rheumatism ;  its  early  attacks  are  apt  to  recur  with  a  certain 
amount  of  periodicity,  and  last  about  a  week, — therefore  a  much 
shorter  time  than  those  of  rheumatic  fever.  During  the  parox- 
ysm of  gout  the  urine  is  scanty,  and  both  before  the  attacks  and 
during  the  first  days  the  uric  acid  is  strikingly  diminished. 

Gout  occurs  generally  in  those  who  live  high  or  who  drink 
large  quantities  of  malt  liquor,  especially  in  men  about  middle 
age,  or  is  seen  in  those  whose  systems  have  been  impregnated 
with  lead ;  while  rheumatism  is  usually  seen  in  the  weak,  is 
excited  by  cold  and  damp,  is  as  common  in  females  as  in  males, 
and  is  oftener  found  in  the  young  and  before  middle  age.  Gout 
is  frequently  combined  with  a  deposition  of  chalk-stones  in  the 
joints;  rheumatism  never.  Then,  as  shown  by  Garrod,*  we 
possess  an  absolute  means  of  diagnosis  in  the  examination  of  the 
blood.  Uric  acid  is  always  present  in  large  excess  in  gout,  and 
absent  in  rheumatism.  This  test  will  render  easy  of  discrimina- 
tion even  those  cases  which,  with  the  usually  employed  means 
now  at  our  command,  are  very  perplexing  to  distinguish.  Nor 
is  the  method  of  detecting  the  uric  acid  difficult,  if  we  make  use 
of  Garrod's  ingenious  plan.  It  consists  in  obtaining  the  crystals 
of  uric  acid,  crystallized  on  a  thread  placed  in  a  mixture  of  the 
serum  of  the  blood  or  of  the  fluid  from  a  blister  with  acetic  acid, 
in  the  proportion  of  six  minims  of  the  acid  to  each  fluid-drachm 
of  the  serum.  The  mixture  of  the  serum  and  acid  with  the  thread 
in  it  is  placed  in  a  shallow  watch-glass  and  allowed  to  stand  from 
twenty-four  to  forty-eight  hours,  protected  from  the  dust. 

The  remarks  just  made  apply  more  especially  to  the  distinction 
between  acute  gout  and  acute  rheumatism.  The  chronic  disorders 
are  more  difficult  to  separate.  Indeed,  unless  there  be  external 
deposits  or  chalk-stones,  their  discrimination  may  be  impossible. 
In  these  obscure  cases,  however,  the  history  and  an  examination 
of  the  blood  may  throw  considerable  light  on  the  diagnosis.  In 
many  subjects,  too,  the  exploration  of  the  external  ear  will  assist 
us  in  arriving  at  a  correct  diagnosis  :  we  find  one  or  several  spots 
of  deposit  of  urate  of  sodium  on  the  helix. 

*  Gout  and  Kheumatic  Gout,  2d  edit.,  London,  1863. 


814  MEDICAL    DIAGNOSIS. 

Gouty  persons  are  subject  to  indio-estion,  flatulency,  pains  and 
ci'anips,  or  palpitation  of  the  heart, — phenomena  which  are  due 
to  the  gouty  poison,  and  which  are  genemlly  ameliorated  by  a  fit 
of  gout.  Tiie  teeth  of  those  of  gouty  diathesis  arc  remarkably 
well  enamelled,  enduring,  and  free  from  decay  ;  but  there  is  great 
proneness  for  tartar  to  collect  upon  them.*  Violent  fits  of  sneez- 
ing may  be  a  most  annoying  symptom,'}'  and  so  are  deep-seated 
pain  in  the  tongue  and  a  sense  of  burning.^  In  chronic  gout 
there  are  often  knotty  finger-joints  and  tophaceous  deposits  in 
fingers  and  toes.     Gouty  endarteritis  is  also  not  uncommon. 

The  gouty  inflammation  of  the  joints  may  retrocede  during  an 
attack,  and  severe  epigastric  pain,  nausea,  vomiting,  flatulence  and 
acidity,  faintness  and  a  feeling  of  sinking,  and  a  quick,  feeble 
pulse  show  that  the  morbid  action  is  transferred  to  the  stomach ; 
or  it  flies  to  the  head,  and  apoplexy  or  maniacal  symptoms  occur; 
or  to  the  heart,  and  there  is  violent  palpitation,  with  dyspnoea,  and 
intense  anxiety ;  or  it  attacks  the  spinal  cord,  and  a. sense  of  con- 
striction around  the  thorax  and  abdomen,  and  piercing  pains  in 
the  limbs,  like  those  of  locomotor  ataxia,  are  encountered,  and  the 
spinal  dura  mater  and  the  roots  of  the  spinal  nerves  are  found  to 
be  incrusted  with  uric  acid  and  urate  of  sodium. § 

Closely  connected  with  gout  is  Uthsemia.  Indeed,  the  excessive 
formation  of  lithates  and  the  dyspeptic  symptoms,  with  the  heart- 
burn and  eructations,  the  signs  of  functional  derangement  of  the 
liver,  the  vertigo,  the  mental  gloom  or  the  listlessness  and  indis- 
position to  exertion,  the  cramps  in  the  legs  and  muscular  twitch- 
ings,  the  neuralgic  attacks,  the  restless  nights,  the  palpitations  of 
the  heart  and  its  irregular  beat,  are  in  many  but  the  precursors, 
although,  it  may  be,  the  long  precursors,  of  a  regular  outbreak  of 
gout ;  while  in  many  more  tliis  half-dyspeptic,  half-nervous  con- 
dition, with  the  faulty  assimilation,  the  imperfect  oxidation,  the 
excessive  discharge  of  lithates  at  times  and  their  disappearance  at 
other  times,  will  go  on  for  years  without  ever  developing  into  an 
attack  of  gout. II     Still,  in  years  the  same  local  lesions  may  follow 

*  Dyce  Duckworth,  Transact.  Odontol.  Soc.  of  Great  Britain,  1883. 

t  Schmidt's  .Jahrbiicher,  No.  8,  1881. 

f  Dyce  Duckworth  on  Gout,  London,  1889,  p.  87. 

g  Ollivier,  Archives  de  Physiologic,  1878. 

II  See  paper  on  Lithsemia,  by  the  author,  Amer.  Journ.  iled.  Sci.,  Oct.  1881. 


EHEUMATJSM    AND   GOUT.  815 

in  internal  organs ;  we  may  have  the  same  form  of  contracting 
kidney,  and  the  heart-affection  with  hypertrophy  and  the  accent- 
uated second  aortic  sound  of  the  litlitemic  state. 

Rheumatic  Arthritis  or  Rheumatic  Gout. — Gout  is  rare 
in  this  country.  But  the  same  cannot  be  said  of  that  distressing 
disorder  known  as  rheumatic  gout,  but  which  is  neither  rlieuma- 
tisni  nor  gout,  but  a  distinct  affection.  The  disorder  may  be 
acute  or  chronic.  It  is  not  often  the  former ;  many  of  tlie  acute 
cases,  indeed,  being  rather  subacute  than  acute.  Even  in  those 
belonging  to  the  acute  form  there  is  little  febrile  disturbance;  and 
though  we  observe  pain  and  aching  in  the  joints,  and  some  discol- 
oration, we  find  less  redness  than  in  acute  rheumatism,  and  cer- 
tainly the  tongue  less  furred,  the  pulse  not  so  bounding,  much 
less  profuse  perspiration,  no  such  heavy  deposits  in  the  urine,  and 
an  utter  freedom  from  cardiac  complication.  The  acute  arthritic 
disease  has  rather  inflammation  of  the  pleura  and  of  the  eye  as 
its  attendants,  and  is  often  accompanied  by  a  sallow  skin,  yellow- 
ish conjunctiva,  and  discolored,  costive  stools.  It  implicates  the 
large  and  small  joints  equally,  thus  differing  from  gout,  and  causes 
very  great  swelling,  due  to  an  effusion,  not  around  the  joint,  but 
into  its  capsule.  It  fastens  upon  several  joints,  and,  though  it  may 
pass  from  joint  to  joint,  it  shows  but  little  migratory  tendency;  the 
joints  first  attacked  remain  the  seat  of  disease.  Unlike  gout,  it 
is  apt  to  affect  the  smaller  joints  of  the  hands  without  a  previous 
affection  of  the  toes,  and  exhibits  no  periodic  paroxysms  or  exacer- 
bations. Moreover,  an  acute  attack  is  of  very  much  longer  dura- 
tion. Unlike  subacute  rheumatism,  it  does  not  affect  the  muscles, 
and  is,  both  in  the  suffering  at  the  time  and  in  its  ultimate  results, 
a  much  graver  malady. 

The  great  danger  in  rheumatic  arthritis  is  from  the  effects  of 
the  inflammation  on  the  joints.  The  changes  there  produced 
are  obvious  in  the  chronic  form,  for  each  joint  attacked  is  apt 
to  be  much  damaged.  The  chronic  complaint  may  follow  the 
acute,  or  it  may  begin  without  any  febrile  symptoms,  with  pain 
and  stiffness  in  the  joints.  These  soon  become  much  distended 
with  fluid,  which  is  gradually  absorbed,  and  the  structure  of  the 
joint  alters,  th.e  cartilages  become,  sooner  or  later,  implicated,  and 
gradually  waste,  and  chronic  changes  and  permanent  deformity 
are  produced.    The  alterations  may  go  on  getting  worse  and  worse 


816  MEDICAL    DIAGNOSIS. 

in  consequence  of  repeated  attacks,  initil  complete  immobility 
ensues,  and,  the  joints  becoming  permanently  atFected,  the  ends 
of  the. bones  are  dislocated  and  enlarged.  But,  though  there  is 
much  swelling,  no  deposits  of  urate  of  sodium  are  found  in  the 
joints. 

Charcot  has  pointed  out  that  in  imralysis  agitans,  in  addition  to 
rigidity  of  the  muscles,  deformities  of  the  fingers  result  resembling 
closely  those  of  chronic  articular  rheumatism.  But  the  likeness 
to  the  deformities  caused  by  rheumatic  arthritis  is  still  closer,  and 
to  distinguish  them  we  must  take  into  account  the  whole  history 
of  the  case,  the  tremor,  the  fixed  look,  the  peculiar  gait,  the  in- 
distinct speech,  the  tremulous  handwriting,  the  sensation  of  exces- 
sive heat.  Moreover,  the  disfigured  joints  are  not  stiff,  and  do 
not  crack.  The  arthropathies  of  locomotor  ataxia  may  be  mis- 
taken for  rheumatoid  arthritis,  but,  irrespective  of  the  history 
and  of  the  characteristic  pains,  the  absence  of  the  patellar  tendon 
reflex  distinguishes  them. 

Rheumatic  arthritis  is  more  common  in  females  than  in  males ; 
like  rheumatism,  it  may  be  excited  by  cold  and  damp,  and  is  very 
apt  to  occur  in  the  weak  and  unhealthy.  It  generally,  even  in 
cases  that  recover,  persists  for  months.  Nor  will  it  yield  to 
the  remedies  usually  administered  in  acute  rheumatism ;  nor  to 
colchicum  and  the  alkalies,  so  beneficial  in  gout. 

I  shall  here  add  a  short  description  of  a  disease  of  nutrition  of 
dissimilar  character  to  those  described,  but  having  this  in  common, 
that  it  markedly  affects  the  organs  of  locomotion, — rickets. 

Rickets. — In  this  country  rickets  is  a  comparatively  rare  affec- 
tion, certainly  rare  as  compared  with  its  prevalence  in  England, 
in  Holland,  in  Germany,  and  in  some  other  Continental  States. 
It  is  a  constitutional  disease  of  early  childhood  connected  with  im- 
paired nutrition,  and  is  chiefly  characterized  by  increased  growth 
of  the  epiphyses  and  periosteum,  and  imperfect  ossification,  pro- 
ducing softening  of  the  bones  with  curvatures  and  distortions. 
The  changes  are  most  manifest  in  the  long  bones ;  and  the  amount 
of  organic  matter  in  thera  is  more  than  doubled,  while  the  earthy 
matter  is  scarcely  above  one-third  of  the  normal  quantity.  Be- 
sides the  osseous  changes  there  is  evident  cachexia  ;  and  the  liver 
and  spleen  become  enlarged  and  indurated  from  overgrowth  of 
the  glandular  elements  and  interstitial  development  of  fibroid 


RHEUMATISM    AND    GOUT.  817 

tissue.  A  similar  process  may  also  happen  in  the  kidneys  and  in 
the  lymphatic  glands. 

Insufficient  and  improper  food  is  a  powerful  cause  of  rickets. 
The  malady  may  show  itself  as  late  as  the  seventh  or  eighth  year ; 
but  it  most  generally  sets  in  during  the  first  or  second  year  of  life. 
When  it  leads  to  death,  it  does  so  generally  by  gradual  exhaus- 
tion, by  impairment  of  the  digestive  functions,  by  thoracic  com- 
plications, such  as  extensive  bronchitis,  pleurisy,  collapse  of  the 
lungs  associated  with  bleeding  of  the  thoracic  walls,  by  spasm  of 
the  glottis,  by  convulsions,  or  by  chronic  hydrocephalus.  As  a 
marked  disease  it  does  not  usually  last  longer  than  a  year,  though 
the  results  of  the  osseous  changes  may  long  persist,  and,  affecting 
the  thorax  or  the  pelvis,  prove  eventually  very  injurious.  Yet  in 
time  the  bones  may  lose  their  rickety  condition  and  become  strong 
and  dense,  although  some  curvature  and  deformity  remain. 

The  beginning  of  the  disease  is  insidious.  The  child  makes  no 
attempt  at  walking,  or  ceases  to  walk  if  it  have  commenced.  It 
is  languid,  irritable,  its  face  pale,  its  tissues  flabby.  The  appetite 
fails,  there  are  thirst  and  irregularity  of  the  bowels,  or  the  marked 
signs  of  a  gastro-intestinal  catarrh.  Restlessness  at  night,  a  dis- 
position to  throw  off  the  bedclothes,  profuse  perspiration  about  the 
head,  neck,  and  chest,  while  the  rest  of  the  body  is  hot  and  dry, 
attend  an  irregular  febrile  condition  which  soon  shows  itself; 
while  fear  of  being  touched,  or  general  soreness  or  tenderness  of 
the  body  or  actual  pain,  bespeaks  the  local  process  that  is  going 
on  in  the  bones  and  their  covering.  The  changes  in  the  bones 
now  become  more  and  more  distinct.  The  joints  appear  swollen, 
especially  at  first  the  wrist-joints,  and  when  these  are  examined 
the  lower  extremities  of  the  radius  and  the  ulna  are  found  to  be 
enlarged ;  similar  changes  are  perceived  in  the  tibia  and  fibula, 
and  in  the  elbow.  There  is  tenderness  along  the  ribs^  and,  should 
the  affection  continue,  nodules  are  felt  at  the  junction  of  the  ribs 
with  their  cartilages ;  the  sternum  protrudes,  a  pigeon-breast  re- 
sults ;  then  the  limbs  show  contortions,  the  clavicles  are  bent,  the 
spine  may  be  curved,  the  pelvis  deformed.  The  head  is  large  and 
square,  the  forehead  high,  the  anterior  fontanel  remains  unclosed, 
the  sutures  are  open  and  thickened  on  the  sides.  A  blowing 
sound  is  frequently  to  be  perceived  over  the  cranial  sutures.  Den- 
tition is  delayed,  or  the  teeth  decay  and  fall  out.     The  urine  is 

52 


818  MEDICAL   DIAGNOSIS. 

copious,  and  contains  lactic  acid  and  an  excess  of  phosphates.  In 
advanced  cases  the  symptoms  of  cachexia  are  very  marked  ;  the 
flabby  muscles,  the  wan,  anaemic  aspect,  the  large  abdomen  con- 
trasting with  the  small  face,  the  enlarged  liver  and  s[)lcen,  the 
persistent  tenderness  over  the  bones,  and  at  times  the  marked 
fever,  give  sad  evidence  of  altered  nutrition  and  of  suffering ;  yet 
even  then  the  little  patient  may  recover,  though  most  likely  with 
part  of  the  osseous  system  irretrievably  damaged.  Of  course  we 
have  all  kinds  of  gradations  in  the  malady,  and  the  general 
symptoms  attending  the  morbid  process  may  be  slight,  just  as 
the  rickety  condition  of  the  bones  may  be  limited. 

The  diagnosis  will  have  been  made  apparent  from  the  descrip- 
tion of  the  symptoms.  In  advanced  cases  there  can  be  no  doubt. 
The  changes  in  the  bones,  the  curvature,  the  distortions,  the  ap- 
pearance of  the  patient,  the  evidences  of  cachexia,  clearly  stamp 
the  malady.  Earlier  in  the  disease  it  may  be  confounded  with 
the  manifestations  of  hereditary  syphilis.  But  this  affection  comes 
on  even  sooner  than  rickets,  almost  from  birth ;  there  are  other 
signs  of  the  constitutional  taint,  including  early  enlargement  of 
the  spleen,  syphilitic  coryza,  and,  at  a  later  period,  the  notched 
teeth  ;  a  distinctive  history  may  perhaps  be  obtained ;  and  the 
enlarged  Ijones  not  unfrequently  suppurate,  the  swollen  epiphyses 
become  detached,  and  osteophytes  form, — changes  not  met  with  in 
rickets. 

3Iollities  ossiimi  produces  deformities  w^hich  may  be  mistaken  for 
those  of  rickets.  But  the  softening  of  the  bone  is  the  result  of  its 
disease,  and  not  of  its  want  of  proper  ossification.  There  is  consid- 
erable difficulty  in  locomotion,  and  the  bones  bend  or  break,  after 
having  been  affected  with  deep-seated  pains.  The  malady  lasts  for 
years,  and  is  not  one  of  childhood,  being  most  common  between 
the  ages  of  twenty-five  and  forty,  and  attacking  chiefly  women. 
The  pelvic  bones  are  often  implicated ;  it  is  doubtful  if  the  phos- 
phates in  the  urine  are  increased,  but,  as  in  rickets,  the  urine  con- 
tains lactic  acid.  But  there  are  not  the  characteristic  signs  at  the 
cranial  bones,  the  open  fontanel  and  sutures,  nor  the  swelling  of 
the  epiphyses,  which  this  malady  so  strikingly  presents. 

Some  of  the  local  deformities  that  result  and  the  diseases  with 
which  they  may  be  confounded,  as  of  the  thorax  and  of  the  head, 
have  been  elsewhere  discussed.    Besides  the  alteration  of  the  skull 


EHEUMATISM    AND   GOUT:  819 

in  chronic  hydrocephalus,  the  condition  described  by  Elsaesser  and 
others  as  craniotabes  may  be  mistaken  for  ordinary  rickets.  It 
consists  in  thinning  of  the  bones  of  the  cranium,  especially  of 
the  occipital  bone,  which  becomes  perforated,  allowing  the  mem- 
branes of  the  brain  to  come  in  contact  with  the  under  surface  of 
the  scalp,  and  convulsions  may  be  induced  by  undue  pressure  over 
the  points  of  perforation  of  the  bone.  The  malady,  though  re- 
garded by  some  as  a  separate  affection,  is  by  others,  by  Virchow 
among  them,  looked  upon  as  due  to  a  rachitic  diathesis ;  we  cer- 
tainly often  find  evidences  of  this  in  conjunction  with  the  peculiar 
alteration  of  the  bones  of  the  skull. 

There  are  cases  described  as  acute  rickets  which  are  a  combina- 
tion of  rickets  and  of  scurvy.*  In  the  early  stages  rickets  may 
be  mistaken  for  acute  or  subacute  rheumatism  ;  the  fever,  the  pain, 
the  sweats,  and  the  swelling  near  the  joints  mislead.  But  the  age, 
the  size  of  the  epiphyses,  the  absence  of  redness  of  the  joints  and 
of  heart-lesion,  the  "beading"  of  the  ribs,  the  signs  of  beginning 
cachexia,  the  faulty  dentition,  and  the  pale  urine  full  of  phos- 
phates, tell  the  true  meaning  of  the  symptoms.  Moreover,  the 
apparent  joint-affection  is  apt  to  show  itself  at  the  wrist-joints, 
always  a  suspicious  circumstance  in  delicate  young  children. 

*  St.  Louis  Courier  of  Medicine,  1S83,  p.  453 ;  also  Barlow,  British  Medical 
Journal,  1883,  i. 


CHAPTER   XII. 

FEVERS. 

Fever  is  either  a  symptom  of  some  strictly  local  malady  or 
constitutes  the  only  obvious  aifection  present.  It  is  only  in  the 
latter  case  that  the  disorder  merits  the  name  of  essential  fever. 
The  first  step,  therefore,  when  fever  has  been  recognized,  is  to 
determine  whether  it  is  symptomatic  or  idiopathic  ;  whether,  in 
other  words,  it  is  but  a  complement  to  a  disease,  or,  as  far  as  can 
be  ascertained,  the  disease  itself.  This  is  not  generally  a  difficult 
matter.  The  history  of  the  case,  the  absence  or  presence  of  the 
marked  peculiarities  of  serious  local  disturbances,  soon  determine 
the  scale  of  evidence  to  rise  on  the  one  side  or  sink  on  the  other. 
And  it  is  astonishing,  with  the  progress  of  medicine,  how  many 
aifections  have  been  passed  over  from  the  domain  of  fevers  to  the 
narrower  circle  of  inflammation  of  individual  organs ;  with  what 
a  different  eye,  for  instance,  the  brain  and  lung  fevers  of  the  olden 
times  are  regarded.  While  thus  the  group  of  idiopathic  fevers 
has  been  considerably  winnowed,  some  of  their  broad  traits  have 
been  prominently  brought  forward.  It  is  now  well  understood 
that,  with  some  exceptions,  they  are  characterized  by  the  want 
of  definite  and  invariable  anatomical  lesions.  That  in  all  con- 
stant changes  occur  in  parts  of  the  nervous  system,  or  in  the 
blood,  is  highly  probable.  But  there  is  certainly  no  invariable 
injury  perceptible  in  the  organs  of  the  body  :  sometimes  one, 
sometimes  another,  suffers ;  sometimes  nearly  all ;  at  times,  none. 
When  we  contrast  this  with  symptomatic  fever,  the  difference  is 
striking.  The  visceral  lesions,  then,  of  an  idioj^athic  fever  are 
not  the  starting-point  of  the  fever,  but  rather  secondary  and  un- 
certain complications  influenced  by  and  subordinate  to  the  pro- 
found disturbance  of  the  whole  system.  In  idiopatliic  fever,  the 
fever  controls  the  lesions  ;  in  symptomatic  fever,  the  lesions  con- 
trol the  fever. 
820 


FEVERS.  821 

Most  fevers  run  a  definite  course,  showing  a  strong  tendency  to 
a  spontaneous  termination  at  a  given  time.  At  their  beginning, 
too,  they  are  for  the  most  part  similar.  There  is  a  prodromic 
state,  marked  generally  by  unsound  sleep,  pain  in  the  back,  and 
lassitude.  This  is  followed  by  chills,  which  are  succeeded  by  lieat 
of  skin,  arrested  secretions,  quick  pulse,  and  evident  fatigue  upon 
the  least  exertion.  The  fever  has  now  reached  its  full  develop- 
ment. Its  precise  character  becomes  evident ;  the  symptoms  caused 
by  disorders  of  individual  organs  stand  forth.  After  a  while  the 
disturbance  declines,  or  speedily  ceases  under  the  influence  of  crit- 
ical discharges.  The  functions  are  re-established,  and  a  convales- 
cence, more  or  less  rapid,  sets  in.  An  unfavorable  termination, 
on  the  other  hand,  may  take  place  at  any  period  after  the  system 
has  been  fairly  invaded. 

The  marked  features  impressed  upon  the  fever  either  by  the 
course  it  runs,  or  by  the  specific  nature  of  the  symptoms,  go  to 
form  what  is  called  its  type,  and  may  be  made  the  basis  of  the 
classification  of  all  febrile  disorders.  But  as  opinions  have  been 
and  are  still  singularly  diversified  as  to  what  really  constitute  the 
most  palpable  characteristics,  so  the  classification  of  fevers  is  as 
yet,  to  a  great  extent,  a  matter  of  speculation.  In  the  following 
table  no  attempt  is  made  at  an  exhaustive  or  strictly  scientific 
classification.  Some  disorders,  such  as  cholera,  epidemic  dysen- 
tery, and  puerperal  fever,  considered  by  many  eminent  patholo- 
gists to  belong  to  idiopathic  fevers,  have  no  place  assigned  to 
them  ;  while  others,  such  as  influenza  and  yellow  fever,  the  claims 
of  which  to  be  here  mentioned  are  undoubted,  might  have  their 
positions  impugned.  But  in  a  diagnostic  point  of  view  the 
arrangement  adopted  is  convenient,  and  is  sufficiently  accurate 
to  be  free  from  grave  objections. 

Fevers. 

f  Simple  continued  fever. 

Catarrhal  fever,  or  influenza. 

Typhoid  fever. 

Continued  Fevers -|  Typhus  fever. 

I   The  plague. 

Cerehro-spinal  fever. 
I  Kelapsing  fever. 


Eruptive  Peters. 


822  MEDICAL   DIAGNOSIS. 

Fevers. — Continued. 

r  Intermittent  fever. 

Periodical  Fevers ]  Remittent  fever. 

j   Congestive  fever. 
t  Yellow  fever. 
'  Scarlet  fever. 

Measles. 

Eubella. 

Smallpox. 

Varicella. 

Miliaria. 

Dengue. 

Erysipelas. 


Continued  Fevers. 

All  continued  fevers  are  characterized  by  a  steady  progress 
of  the  febrile  movement,  without  either  decided  exacerbation  or 
relaxation,  the  rise  and  fall  observable  being  too  slight  to  modify 
the  impression  of  a  sustained  action. 

Simple  Continued  Fever.— Simple  fever  sets  in  with  feel- 
ings of  lassitude  and  chilliness ;  to  these  succeed  hot  skin,  ex- 
cited pulse,  thirst,  headache,  pain  in  the  limbs.  The  bowels  are 
generally  confined,  the  urine  high-colored.  The  fever  is  soon  at 
its  height ;  it  then  either  gradually  declines,  or  is  more  suddenly 
relieved  by  copious  perspiration  or  by  a  critical  discharge  from 
the  bowels.  Generally  it  runs  through  all  these  stages  in  a  few 
days ;  but  it  may  be  protracted  for  upward  of  a  week.  On  the 
other  hand,  a  day  may  witness  both  its  beginning  and  its  termi- 
nation.    The  convalescence  is  almost  always  rapid. 

The  exciting  causes  of  this  form  of  fever  are  fatigue,  errors  in 
diet,  change  in  mode  of  life,  exposure  to  cold  and  moisture,  or  to 
the  sun.  When  brought  on  by  mental  overwork  or  by  anxiety  or 
grief,  it  is  not  uncommonly  attended  with  increased  sensibility  of 
the  skin,  and  with  considerable  prostration,  simulating  typhoid 
fever,  but  differing  from  it  by  the  absence  of  epistaxis,  of  the  pe- 
culiar abdominal  symptoms,  and  of  the  eruption.  More  frequently 
the  fever  has  the  appeamnce  of  one  of  high  action.  At  times,  in- 
deed, it  is  so  intense,  and  the  vascular  system  is  so  wrought  up, 
that  the  distemper  assumes  what  is  called  an  inflammatory  type. 
It  then  exhibits  the  characteristics  of  the  fever  described  bv  the 


FEVERS.  823 

physicians  of  the  last  century  as  synocha.  A  temperature  of  10'3° 
or  upward,  throbbing  of  the  temporal  arteries,  severe  headache, 
and  delirium  are  among  its  symptoms.  This  variety  of  the  fever 
is  not,  however,  now  encountered,  save  in  tropical  latitudes.  In 
point  of  diagnosis,  it  is  most  apt  to  be  confounded  with  internal 
inflammations,  especially  with  inflammation  of  the  brain.  On 
the  history  of  the  case,  and  on  the  full  consideration  of  all  the 
symptoms  before  us,  alone  can  a  trustworthy  opinion  be  based. 
In  truth,  in  all  the  grades  of  what  appears  to  be  at  first  sight 
simple  continued  fever,  we  ought  to  examine  carefully  all  the 
organs  and  see  whether  the  symptoms  may  not  be  wholly  ac- 
counted for  by  some  visceral  disturbance.  And  often,  then,  under 
what  seems  to  be  a  very  active  or  "  ardent"  fever  will,  on  closer 
scrutiny,  be  found  lurking  the  traits  of  an  inflammatory  lesion. 

Catarrhal  Fever. — This  epidemic  malady,  which  belongs  to 
the  idiopathic  fevers,  is  often  described  as  a  mere  variety  of 
bronchitis,  because  inflammation  of  the  bronchial  mucous  mem- 
brane constitutes  one  of  its  most  prominent  symptoms.  But  this 
is  not  a  just  view.  With  as  much  reason  might  typhoid  fever 
be  omitted  from  the  list  of  febrile  maladies  and  described  as  a 
variety  of  enteritis  or  of  diarrhoea. 

Catarrhal  fever,  or  influenza,  is  essentially  an  epidemic  disease, 
and  one  which  has  visited  the  human  race  from  remote  antiquity. 
Its  history  is  thus  not  confined  to  any  particular  time  or  to  any 
particular  nation ;  yet,  in  spite  of  its  frequency  and  wide  preva- 
lence, its  cause  is  still  unascertained.  Each  epidemic  does  not 
furnish  precisely  the  same  train  of  symptoms ;  but  they  all  agree 
in  this  :  the  disorder  sets  in  suddenly,  and  attacks  pre-eminently 
the  mucous  membranes.  Generally  it  is  the  mucous  membrane 
of  the  nose,  eyes,  and  bronchial  tubes  which  suffers  most,  and  we 
find  the  signs  of  coryza  and  of  bronchial  inflammation, — a  w^atery 
eye,  sneezing,  uneasiness  about  the  throat,  and  a  tormenting  cough. 
But  associated  Avith  these  are  great  depression  of  spirits  and  usually 
an  extraordinary  amount  of  lassitude  and  impairment  of  strength ; 
much  more  than  the  cold  in  the  head,  or  the  laryngitis,  or  the  bron- 
chitis, will  account  for.  The  skin  is  hot,  at  times  covered  with  per- 
spiration ;  the  thermometric  record  is  peculiar  only  in  its  extreme 
irregularity,  but  generally  ranges  between  100°  and  102°,  or  starts 
up  suddenly  to  104°  or  105°,  and  in  less  than  a  day  subsides  almost 


824  MEDICAL   DIAGNOSIS. 

to  normal  ;  the  pulse  is  of  moderate  volume,  or  weak,  the  tongue 
Nvlnte  and  coated  ;  the  patient  complains  of  debility,  of  headache, 
of  aching"  pains  in  his  back  and  limbs,  and  of  constriction  at  the 
lower  part  of  the  chest.  Often  there  is  some  dyspntiea  as  well  as 
epistaxis,  hypersesthesia,  especially  of  the  neck  and  lK'a<l,  and  dis- 
turbance of  the  alimentary  tract,  evinced  by  loss  of  a])])ctite,  nausea, 
and  vomiting,  or  by  diarrhoea;  at  times  catarrhal  jaundice  coexists. 
Commonly  after  three  or  four  days  these  symptoms  begin  to  sub- 
side, the  cough  and  debility  outlasting  the  other  morbid  signs. 
AVith  reference  to  the  cough,  we  are  often  struck  by  the  fact  that 
its  obstinacy  and  violence  are  not  associated  with  adequate  physical 
signs  of  disorder.     It  is  often  very  dry  and  harassing. 

But  all  epidemics  do  not  run  precisely  this  course.  In  some, 
the  prostration  is  not  so  evident,  and  the  febrile  signs  are  more 
active  and  of  an  inflammatory  type;  in  others,  the  pain  and  sore- 
ness in  the  limbs  and  in  the  joints  are  the  most  prominent  symp- 
toms ;  or  we  may  find  hemicrania,  or  torpor  and  delirium,  or  paro- 
titis with  salivation,  or  otitis,  or  epistaxis,  or  jaundice,  or  capillary 
bronchitis,  or  pneumonia,  or  tendency  to  heart  failure,  or  menin- 
gitis, basilar  or  spinal,  and  irregular  rashes,  as  complications. 

Influenza  is  not  ordinarily  in  itself  a  fatal  disease.  It  is  only 
so  in  the  very  young  or  the  very  old,  in  both  of  whom  it  is  apt  to 
become  combined  with  inflammation  of  the  smaller  bronchial  tubes 
or  of  the  lung,  which  are  not  only  serious  at  the  time,  but  are  apt 
to  leave  chronic  bronchial  catarrh  or  indurated  lungs  behind.  It 
is  also  a  very  grave  malady  in  those  with  Aveak  hearts. 

Catarrhal  fever  is  easily  discriminated  from  other  maladies.  Its 
peculiar  epidemic  character  and  the  prostration  prevent  us  from 
mistaking  an  ordinary  cold  or  bronchitis  for  it.  Occasionally  the 
attending;  debilitv  makes  it  look  like  the  onset  of  a  low  continued 
fever.  But  brain-symptoms  are  present  only  in  rare  instances  in 
influenza ;  and,  on  the  other  hand,  decided  catarrhal  s}'mptoms 
are  not  common  in  typhoid  or  typhus  fever.  Before  long,  too, 
the  occurrence  of  the  eruption  of  these  diseases  clears  up  what- 
ever doubt  may  have  existed.  The  all  but  constant  absence  of  an 
eruption  in  influenza  comes  also  elsewhere  into  play  :  it  serves  to 
distinguish  this  disorder  from  measles  or  smallpox. 

Catarrhal  fever  may  be  mistaken  for  hay-fever.  But  the  local 
symptoms  of  irritation  of  the  nostrils,  and  even  of  the  bronchial 


FEVERS.  825 

mucous  membrane,  are  much  more  severe  in  the  latter  than  in 
the  former;  the  watery  eyes  and  reddened  conjunctivae  are  very 
striking,  and  the  febrile  movement  is  generally  less  than  in  catar- 
rhal fever.  Moreover,  there  are  asthmatic  symptoms  in  hay-fever 
or  hay-asthma  in  a  certain  proportion  of  cases ;  and  the  history 
of  the  case;  the  manner  in  which  it  comes  on  as  a  rose-cold  in  the 
latter  part  of  May  or  early  in  June,  or  as  autumnal  catarrh  after 
the  middle  of  August;  the  hereditary  idiosyncrasy  so  often  sften; 
the  persistence  of  the  attack  while  exposed  to  the  peculiar  vege- 
table emanations  which  give  rise  to  it;  its  almost  abrupt  cessation 
on  removal  to  certain  localities, — make  up  a  set  of  features  which 
are  very  distinctive. 

When  influenza  is  prevailing  on  a  large  scale,  it  is  often  found 
peering  out  from  under  the  garb  of  other  diseases,  and  it  may  be 
difficult  then  to  separate  its  manifestations  from  those  of  the  mal- 
ady it  accompanies.  Other  peculiarities  of  influenza  are  the  long 
time  it  takes  the  patient  to  regain  his  strength,  and  the  annoying 
sweats  that  attend  the  convalescence.  This  was  very  striking  in 
the  epidemic  of  the  early  winter  months  of  1890  ;  as  was  also  the 
tendency  to  relapses,  to  irregular  heart-action,  and  to  alterations 
of  cutaneous  sensibility. 

Typhoid  Fever. — In  this  country  and  on  the  continent  of 
Europe  a  form  of  continued  fever  prevails,  marked  by  great  pros- 
tration and  disturbance  of  the  nervous  system,  and  by  constant 
anatomical  lesions.  To  this  disease  the  designations  of  typhoid 
fever,  enteric  fever,  and  abdominal  typhus  have  been  applied. 

The  disorder  either  attacks  single  individuals  or  shows  itself 
as  an  epidemic.  It  occurs  at  all  seasons  of  the  year,  but,  in  this 
country  at  least,  is  most  frequent  in  autumn.  In  some  localities 
it  is  thoroughly  at  home ;  in  others  it  is  only  occasionally  seen. 
It  avoids  both  extremes  of  age,  seizing  mainly  on  young  adults 
for  its  victims.     Its  chief  exciting  cause  is  defective  sew^erage. 

The  distemper  may  set  in  suddenly,  but  more  generally  it  has 
an  insidious  beginning.  For  some  days  preceding  the  access  of 
the  fever  the  patient  feels  weak.  He  is  without  animation,  and 
his  countenance  fully  expresses  his  languor.  He  complains  of 
soreness  and  fatigue,  of  dull  pain  in  the  head,  of  loss  of  appetite. 
His  sleep  is  unsound ;  all  exertion  is  wearisome ;  something  is 
evidently  weakening  his  nervous  energies.     A  fever  now  appears, 


826  MEDICAL    DIAGNOSIS. 

proeodcd  mostly  bv  a  chill,  or,  at  all  events,  by  chilly  sensations, 
wJiich  alternate  with  flushes  of  heat.  The  nuiscular  prostration 
accompanying-  the  febrile  movement  is  so  great  that  the  patient  is 
obliged  to  seek  his  bed.  His  appetite  is  entirely  g(me,  the  tongue 
is  coated,  the  bowels  are  loose,  the  abdomen  is  somewhat  swollen 
and  lender  to  the  touch.  On  close  inspection,  a  few  reddish  spots, 
resend)ling  lica-bites,  are  found  on  its  surface. 

The  malady  has  now  completed  its  first  week.  It  enters  the 
second  week  with  fever  unabated,  and  with  the  signs  of  disturb- 
ance of  the  alimentary  tract  and  of  the  nervous  system  more  and 
more  unmistakable.  There  is  sometimes  nausea  or  epigastric  dis- 
tress, often  pain  in  the  right  iliac  fossa,  increased  by  pressure  and 
tympanites.  The  tongue  dries  and  becomes  reddish  or  brownish  ; 
it  is  often  glazed  and  covered  with  a  light  coat ;  sometimes  it  has 
deep  fissures ;  very  frequently  I  have  noticed  at  the  tip  a  wedge 
of  brownish  or  reddish  surface  free  from  coat,  but  Avhich  begins 
to  be  covered  over  as  the  disease  declines ;  the  gums  and  teeth  are 
lined  with  dark  crusts.  The  mind  is  dull  and  wandering ;  cough 
and  great  restlessness  exist ;  the  debility  is  extreme. 

The  disease  now  begins  to  draw  to  its  close.  It  has  reached 
the  third  week,  and  a  change,  for  better  or  for  worse,  may  be 
looked  for.  Slowly  recovery  sets  in,  marked  by  a  brightening 
of  the  countenance  and  by  a  gradual  increase  in  consciousness 
and  strength  ;  or  deepening  insensibility,  jerking  of  the  tendons, 
feeble  pulse,  and  cold,  clammy  sweats  indicate  that  dissolution  is 
fast  approaching. 

Thus,  in  one  way  or  the  other,  the  fever  itself  is  apt  to  ter- 
minate by  the  beginning  or  the  middle  of  the  fourth  week.  Yet 
such  is  not  always  the  case.  Death  may  take  place  at  an  earlier 
period ;  or,  on  the  other  hand,  the  malady,  by  troublesome  com- 
plications, may  be  lengthened  beyond  the  second  month.  Under 
any  circumstances,  convalescence  is  protracted.  The  nervous 
svstem  rallies  but  gradually  from  the  shock  it  has  received. 

Among  the  symptoms  enumerated,  some  tend  clearly  to  charac- 
terize the  disease.  And,  first,  of  the  more  purely  febrile  symptoms. 
The  heat  of  the  skin  is  especially  perceptible  in  the  evening  ex- 
acerbations of  the  fever.  Frequently  the  surface  is  covered  Avith 
an  acid  perspiration,  very  manifest  during  the  whole  course  of  the 
disorder,  and  also  encountered  long  after  convalescence  has  set  in. 


FEVERS.  827 

The  pulse  is  accelerated,  and  remains  so  after  the  heat  of  the  skin 
has  left ;  it  is  very  compressible,  and  even  in  intercurrent  a'cute  in- 
flammations it  seldom  loses  its  compressibility.  A  jerking,  irreg- 
ular beat,  or  very  great  rapidity,  is  an  unfavorable  sign.  Dicrotism 
of  the  pulse  is  not  unusual.  Associated  with  the  diminished  strength 
of  the  pulse  is  a  decided  faintness  of  the  first  sound  of  the  heart. 

The  temperature  is  peculiar ;  in  the  first  five  or  six  days  of  the 
disease  it  piirsiies  an  ascending  line ;  that  is  to  say,  that,  starting 
at  the  normal  98.6°,  there  is  apt  to  be  a  daily  evening  rise  of 
about  2°,  with  a  morning  remission  of  about  1°.  From  the  fifth 
or  sixth  day  to  the  twelfth  or  a  little  later, — roughly  speaking,  we 
may  say  from  the  end  of  the  first  week  to  the  end  of  the  second, 
— the  fever  is  continuous,  with  a  morning  remission  rarely  exceed- 
ing 1°.  From  that  time  on,  let  us  say  from  the  twelfth  day, 
although  the  evening  temperature  may  remain  for  a  day  or  two 
quite  or  nearly  as  high,  there  is  an  abatement  of  heat  of  1°  to  2° 
in  the  morning.  These  changes  between  morning  and  evening 
become  very  evident  at  the  end  of  the  week,  and  are  still  more 
evident  in  the  third  week,  when  the  morning  and  evening  tem- 
peratures may  vary  as  much  as  from  4°  to  6°.  During  this  week, 
too,  the  evening  temperature  gradually  decreases  ;  but  in  severe 
cases  it  remains  high,  and  there  are  no  decided  remissions,  either 
in  the  second  or  the  third  week.  The  morning  temperature  is  high, 
104°  or  more,  and  there  may  be  still  greater  heat  of  skin  in  the 
evening,  or  else  it  differs  but  little  from  that  of  the  morning. 
The  peripheral  temperature,  as  measured,  for  instance,  in  the  palm 
of  the  hand,  becomes  during  the  fever  as  high  as  the  axillary 
temperature,  but  their  equalization  ceases  prior  to  defervescence.* 

The  urine  is  acid,  high-colored,  scanty, — the  urine  of  fever. 
In  severe  cases  it  contains  variable  amounts  of  albumen,  particu- 
larly in  the  cases  with  high  temperature ;  hsematuria  is  very  rare. 
Lately  Ehrlich  has  stated  that  the  urine  of  typhoid  fever  gives  a 
special  reaction.  This  test  consists  in  taking  twenty-five  parts  of 
a  saturated  solution  of  sulphanilic  acid  in  hydrochloric  acid  (one 
to  twenty)  and  one  part  of  a  five-per-cent.  solution  of  sodium 
nitrite,  and  adding  them  to  an  equal  bulk  of  urine  rendered 
alkaline  by  strong  ammonia.     Normal  urine  is  colored  brown- 

*  Gouty,  Archives  de  Physiologic,  No.  2,  1880. 


828 


MEDICAL   DIAGNOSIS. 


ish  by  the  test   liquid,  typhoid -fever  urine   pink  or    ruby,  with 
slight  frothing.     Taylor*  reports  that  he  found  the  reaction  in 


llggllMMIMIMIIIiaillgMllMMIlMMMIlEailMiiilMMMIMMlBIMMM 


111 


^■■.■■■■■■■■■■■■■^^■■■■■■■■■■■■■■■■■■■■-„„l,l,„,,„y,,„„„,, 


'■■■■""""■"■ 


typhoid,  not  in  simple  febricula  or  in  catarrhal  fever,  but  in  a 
case  of  acute  phthisis. 

*  Lancet,  May  4,  1889. 


FEVERS.  829 

Among  the  abdominal  symptoms,  diarrhoea  is  the  most  promi- 
nent. It  is  never  absent,  except  when  the  disease  is  unusually 
mild.  Generally  it  is  a  very  early  symptom ;  at  times  it  is  even 
seen  among  the  prodromes.  The  clue  to  its  cause  is  found  in  the 
state  of  the  abdominal  glands, — in  the  enlargement  and  ulcera- 
tion of  the  glands  of  Peyer  and  of  the  solitary  glands,  and  in 
the  tumefaction  of  the  mesenteric  glands.  And  in  these  morbid 
alterations  we  find  an  explanation  not  only  of  the  occurrence  of 
the  diarrhoea,  but  also  of  its  frequency.  The  stools  are  thin,  of  a 
yellow  or  dark-brown  color,  and  of  offensive  smell.  When  the 
affection  is  at  its  height,  from  three  to  four  evacuations  occur 
during  the  twenty-four  hours  ;  but  the  passages  may  become 
much  more  numerous,  and  with  their  number  the  danger  rises. 
If  they  take  place  without  the  knowledge  of  the  patient,  his  situ- 
ation is  precarious.  Sometimes  the  stools  contain  blood.  Should 
this  be  23 resent  in  considerable  quantity,  it  is  a  very  unfavorable 
circumstance.  Yet  intestinal  hemorrhage  is  by  no  means  neces- 
sarily fatal.     In  rare  instances  there  is  hsematemesis.* 

From  the  stools  we  may  obtain  bacilli ;  and  one  form  of  these, 
the  typhoid-fever  bacillus  of  Gaffky  (Fig.  62),  is  regarded  as 
characteristic.  It  is  of  the  diameter  of  a  red  corpuscle,  and  is 
best  stained  by  a  saturated  watery  solution  of  methyl-blue. 

Enlargement  of  the  spleen  is  a  very  constant  attendant  upon  the 
fever.  In  fact,  whenever  we  can  be  certain  that  the  evident  in- 
crease in  size  is  not  due  to  some  previous  malady  or  to  malaria, 
the  extended  percussion  dulness  in  the  splenic  region  becomes  an 
element  of  importance  in  our  diagnosis.  The  tympany  which 
often  exists  interferes  with  the  recognition  of  the  enlargement. 

Another  abdominal  symptom  of  significance  is  "pain.  It  varies 
much  in  severity  and  character,  and  is,  indeed,  not  always  present. 
Is  is  often  a  heavy,  aching  feeling.  In  some  patients  it  is  of  a 
griping  kind,  preceding  the  loose  discharges;  in  others  it  seems 
to  be  called  into  existence  only  by  pressure.  Its  most  common 
seat  is  in  the  iliac  fossae ;  yet  the  testimony  of  the  sick  man  him- 
self as  to  its  exact  situation  must  be  received  cautiously.  He  is 
too  ill  to  answer  intelligently.  Still,  the  expression  of  suffering 
on  his  face  when  pressed  on  either  side  at  the  lower  part  of  the 

*  Weiss,  Wien.  Med  Presse,  1887. 


830 


MEDICAL    DIAGNOSIS. 


abdomen  is  indicative  of  the  pain  corresponding;,  for  the  most 
part,  to  the  seat  of  the  irritation.  In  rare  instances  the  pain  is 
reallv  in  the  muscles,  which  may,  indeed,  suppurate.*      Often, 


Fig.  62. 


Gaffky's  t.vphoid-fpver  bacillus,  from  a  potato  culture.    The  broad  ones  are  really  two 
bacilli  lying  in  juxtaposition.     Zeiss  -^2,  homo,  im.,  Oc.  5. 

while  the  hand  is  exploring  the  abdominal  regions,  a  movement 
of  the  fluid  and  gas  in  the  distended  bowel,  attended  with  a 
gurgling  noise,  becomes  appreciable.  This  sign  is  best  elicited 
near  the  ileo-caecal  valve. 

During  convalescence,  griping  pains  are  not  unfrequently  com- 
plained of.  They  are  colicky  pains,  produced  generally  by  errors 
in  diet,  and  may  be  followed  by  a  return  of  the  diarrhoea  or  by  a 
relapse  of  all  the  other  symptoms  of  the  malady.  Occasionally 
during  the  latter  period  of  the  fever  a  sudden  pain  sets  in,  of 
great  intensity,  unremitting,  and  attended  by  spreading  tender- 
ness. Such  a  pain  shows  that  peritoneal  inflammation  has  been 
lighted  up  in  consequence  of  perforation. 


*  Ebing,  Archiv  fiir  Klin.  Med.,  viii. 


FEVERS.  831 

Hardly  inferior  to  the  abdominal  symptoms  in  import  aro  the 
signs  of  disturbance  of  the  nervous  system.  The  fever  is,  as  its 
old  name  implies,  pre-eminently  a  "nervous"  fever:  the  nervous 
symptoms  are,  in  truth,  never  absent ;  but,  though  always  present, 
they  are  less  extensive  in  some  cases  than  in  others,  and  not  the 
same  throughout  all  the  stages  of  the  disease.  Thus,  early  in 
the  disorder,  dull  headache,  mental  languor,  wakefulness,  and  a 
perverted  state  of  the  senses,  such  as  ringing  in  the  ears  and  dul- 
ness  of  hearing,  are  encountered ;  while  later,  great  restlessness, 
delirium,  somnolence,  or  coma,  and  jerking  of  the  tendons  are 
phenomena  more  likely  to  be  met  with.  The  delirium  especially 
requires  to  be  noted.  It  sets  in  generally  during  the  second  week, 
for  the  most  part  at  night,  and  terminates  with  convalescence  or 
else  ends  in  coma.  It  is  not  a  wild  delirium,  but  a  confusion  of 
mind  associated  with  rambling  thoughts.  If  the  patient's  atten- 
tion be  strongly  engaged,  he  may  almost  always  be  roused,  and  does 
for  a  time  as  he  is  told ;  but  after  a  short  interval  his  muttering 
lips  indicate  that  some  curious  fancy  has  again  taken  possession 
of  him.  In  some  cases,  not  in  many,  the  delirium  is  attended 
with  great  restlessness  and  agitation,  and  the  sick  man,  if  not  pre- 
vented, attempts  to  walk  about  the  room.  This  kind  of  frenzy 
often  ends  in  fatal  coma.  Equally  unpromising  is  early  or  unre- 
mitting delirium.  When  contrasted  with  the  mental  wandering 
in  other  acute  disorders,  the  delirium  of  typhoid  fever  exhibits 
peculiar  traits.  It  is  ordinarily  more  active  than  that  of  typhus; 
far  less  demonstrative  or  talkative  than  the  mania  of  drunkards ; 
as  aimless  as,  but  less  continued  than,  the  ravings  of  inflamma- 
tion of  the  brain.  Great  restlessness  and  tremors,  associated  with 
a  clear  mind,  and  at  times  with  copious  perspirations,  have  a  very 
significant  meaning :  they  point  to  deep  and  extending  ulceration. 

Other  symptoms  of  grave  disturbance  of  the  nervous  system 
show  themselves  in  violent  general  convulsions.  These  are  more 
common  in  children  than  in  adults,  in  whom  they  may  be  a  late 
symptom ;  they  may  or  may  not  be  of  ursemic  origin.  In  all 
instances  of  typhoid  fever  the  knee-jerk  is  always  present. 

In  some  cases  of  typhoid  fever  symptoms  not  only  of  cerebral 
but  also  of  spinal  origin  appear,  and  they  may,  indeed,  assume  a 
high  degree  of  intensity.  We  find  extensive  cutaneous  hyperses- 
thesia,  spinal  pain  and  tenderness,  with  a  sense  of  pricking  along 


832  MEDICAL   DIAGNOSIS. 

the  vertebral  column,  and,  in  sinne  instances,  cntaneons  and  mus- 
cular anaesthesia,  numbness  of  the  extremities,  partial  paralysis 
or  convulsive  contractions  of  the  respimtory  muscles,  convulsive 
cough,  })aralysis  of  the  sphincters,  contractions  of  the  extremities, 
and  even  rigidity  of  the  nuiscles  of  the  neck.*  These  spinal 
symptoms  are  more  common  M'hcn  the  disease  is  epidemic  than 
when  it  is  sporadic,  and  are  always  indicative  of  a  very  serious 
form  of  the  disorder.  They  sometimes  persist  after  the  fever  has 
left,  or  indeed — and  this  is  especially  true  of  paralysis — may  not 
appear  until  convalescence.  The  2:>alsi/,  the  most  common  form 
of  which  is  paraplegia,  mostly  begins  gradually  and  disappears 
gradually.  It  may  be  preceded  by  trembling  movements,  sug- 
gesting the  idea  of  disseminated  sclerosis  ;  but  the  tremor  is  rather 
the  result  of  general  debility,  and,  unlike  sclerosis,  it  occurs  be- 
fore, and  does  not  attend  or  follow,  the  loss  of  muscular  power 
in  the  limbs,  and  is  not  associated  with  difficulty  of  enunciation. 
Much  evidence  has  been  offered  of  late  years  that  the  paralysis 
after  typhoid  fever  is  due  to  neuritis.f 

Two  other  prominent  symptoms  of  the  malady  must  still  be 
inquired  into  :  one  is  epistaxis ;  the  other,  the  cutaneous  eruption. 
Epistaxis  is  not  often  absent  in  grave  cases.  It  may  happen  at 
any  period  of  the  complaint ;  but  it  generally  takes  place  before 
the  disorder  is  far  advanced.  The  quantity  of  blood  lost  is  rarely 
considerable  ;  and  for  this  reason  the  occurrence  of  the  hemorrhage 
is  frequently  overlooked. 

The  eruption  peculiar  to  the  disease  is  the  rose-colored  rash. 
It  appears  on  or  shortly  after  the  seventh  day,  but  occasionally 
not  until  the  end  of  the  second  Aveek.  It  can  hardly  be  called  a 
papular  eruption,  as  it  consists  rather  of  small,  red  spots,  only 
very  slightly  elevated  above  the  skin,  somewhat  similar  to  flea- 
bites,  yet  diifering  from  them  in  lacking  the  central  mark  and  in 
their  finer,  paler  color  and  less  obvious  outline.  The  spots  are 
seen  upon  the  abdomen  and  chest,  rarely  upon  the  extremities, 
almost  never  upon  the  face.  They  disappear  totally  on  strong 
pressure,  yet  return  immediately  when  the  pressure  ceases.     They 

*  Fritz,  Etude  clinique  sur  divers  Symptomes  spinaux  observes  dans  la  Fievre 
typhoide,  referred  to  in  Arch.  Gen.  de  Med.,  June,  1864.' 

t  Pitres  and  Vaillard,  Kev.  de  Med.,  1855,  t.  v. ;  also  Boss,  Amer.  Journ, 
Med.  Sci.,  Jan.  1889. 


FEVERS.  80.5 

are  generally  few  in  number,  and  not  persistent.  Each  spot  does 
not  last  for  more  than  three  or  four  days ;  then  it  fades,  and  a 
fresh  one  near  by  replaces  it,  and  runs  the  same  course.  Spots  thus 
appear  and  pass  away  for  more  than  a  week,  after  which,  in  most 
cases,  they  entirely  vanish.  During  convalescence  not  a  trace  of 
them  €an  be  found  ;  but  should  a  relapse  take  place,  they  reappear 
with  the  other  symptoms  of  the  malady.  This  eruption,  although 
very  common,  is  not  invariably  present ;  at  all  events,  it  is  not  in- 
variably found.  Beyond  doubt,  too,  it  is  in  some  epidemics  more 
constant  and  marked  than  in  others.  Late  in  the  disease  another 
eruption  appears,  consisting  of  minute  transparent  vesicles,  scattered 
plentifully  over  the  body.  These  sudamina  are  not  so  frequently 
encountered  as  the  rose-rash,  and  are  certainly  not  so  characteristic. 
After  convalescence  has  set  in,  we  may  have  a  return  of  fever. 
It  may  be  either  a  transitory  and  slight  return,  due  to  fatigue 
or  to  some  indiscretion  in  diet,  or  a  more  protracted  state,  in 
which  most  or  all  of  the  symptoms  peculiar  to  the  disease  reap- 
pear. Thus,  typhoid  fever  relapses  usually  come  on  in  the  second 
week  of  assured  convalescence,  and,  according  to  my  experience,* 
occur  suddenly ;  soon  diarrhoea,  furred  tongue,  and  enlargement 
of  the  spleen  are  manifest,  and  on  the  fourth  or  fifth  day  reappears 
the  characteristic  rose-rash,  which  is  often  somewhat  coarser  than 
in  the  first  attack,  and  does  not  show  the  same  disposition  to  ap- 
pear in  successive  crops.  With  the  eruption  delirium  is  apt  to 
come  back.  The  temperature  is  unlike  the  original  attack  in 
quickly  reaching  a  high  point  of  fever-heat ;  after  the  first  day  or 
two  it  remains  more  or  less  stationary,  with  a  slight  morning  fall, 
for  five  or  seven  days  usually,  and  then  shows  the  well-known 
remissions  and  rises  producing  the  zigzag  decline.  The  pulse 
is  often  noted  to  be  dicrotic. f  The  relapse  is  in  its  duration 
usually  much  shorter  than  the  original  attack,  and  generally,  not- 
withstanding the  threatening  appearance  of  the  symptoms,  ends  in 
convalescence.  During  its  progress  intestinal  hemorrhage  may 
happen  ;  and  after  return  to  apparent  health  a  second  relapse  may 
occur.  Each  relapse  of  the  malady  occasions  characteristic  mark- 
ings on  the  nails,  from  impaired  nutrition,  which  Longstreth  has 

*  See  article  on  Eelapses  of  Tj^phoid  Fever,  Transactions  of  the  College  of 
Physicians  of  Philadelphia,  1877. 

t  Steinthal,  Arch.  f.  Klin.  Med.,  Feb.  1884. 

53 


834  MEDICAL   DIAGNOSIS. 

very  fully  described.'^  Ziemssen  specifics  the  fifth,  seyenth,  and 
fourteenth  days  after  the  cessation  of  the  original  feyer  attack  as 
the  days  on  \vhich  a  relapse  is  likely  to  happen. f 

Both  durino-  the  height  of  the  foyer  and  in  conyalescence,  but 
more  especially  during  the  latter,  certain  complications  or  scquelas 
may  arise,  some  of  which  arc  medical,  such  as  parotitis,  laryngeal 
ulceration  or  stenosis,  milk-leg,  thrombosis  of  the  femoral  artery, 
the  result  of  arteritis,."};  periostitis,  and  transitory  aphasia  ;  §  while 
others,  as  dislocations,  caries,  necrosis  of  bones,  and  gangrene, 
come  within  the  domain  of  surgery.  || 

After  this  analysis  of  the  symptoms  of  typhoid  fever,  it  would 
be  useless  repetition  to  discuss  at  length  how  the  disease  differs 
from  all  other  idiopathic  fevers.  The  attempt  will  rather  be  made 
to  explain  its  diagnosis  from  thosj  maladies,  whether  essentially 
febrile  or  not,  to  which  it  bears  the  closest  resemblance.  And 
here  we  find  that  the  disorders  with  which  typhoid  fever  may  be 
confounded  are  not  the  same  at  all  the  stages  of  the  complaint. 
Early  in  the  affection  it  is  most  likely  to  be  mistaken  for  simple 
continued  fever,  or  for  one  of  the  exanthemata.  But  diarrhoea  is 
not  present  in  these,  nor  are  there  marked  prodromata  ;  and  what- 
ever doubt  may  exist  with  reference  to  simple  continued  fever  is 
cleared  up  in  a  few  days,  as  the  temperature-record  is  different 
and  as  the  symptoms  come  to  an  end  at  a  time  at  which  in  ty- 
.phoid  fever  they  begin  to  be  more  and  more  developed.  Still, 
the  exanthematous  fevers  cannot,  before  their  eruptions  appear, 
be  distinguished  with  absolute  certainty  ;  though  we  may  suspect 
measles  by  the  attending  coryza,  scarlatina  by  the  sore  throat, 
and  smallpox  by  the  lumbar  pains  and  high  fever. 

At  a  more  advanced  period,  typhoid  fever  may  be  confounded 
with  typhus,  and  with  these  morbid  states  : 

General  Debility; 

Typhoid  Conditions; 

Enteritis  ; 

*  Relapses  of  Typhoid  Fever,  Transact.  Coll.  uf  Phys.  of  Phila.,  1877. 
t  Arch.  f.  Klin.  Mecl.,  Feb.  1884. 

X  Lucas-Championniere,  Journ.  de  Med.  et  de  Chir.  Pratiques,  1888. 
§  Arch.  f.  Klin.  Med.,  Ed.  xxxiv.  1,  1883. 

II  See  an  elaborate  discussion  of  these  surgical  complications,  by  Dr.  W.  W. 
Keen,  Fifth  Toner  Lecture,  Washington,  1877. 


FEVERS.  835 

Peritonitis  ; 

Meningitis  ; 

Ulcerative  Endocarditis  ; 

Acute  Pulmonary  Affections. 

General  Debility, — It  does  not  seem  likely  that  so  acute  and 
dangerous  a  malady  as  typhoid  fever  could  be  mistaken  for  mere 
debility  y  yet  such  an  error  may  occur  where  the  disease  is  latent, 
or  so  light  as  not  to  confine  the  patient  to  his  bed.  In  these  so- 
called  ''  walking  cases"  the  debility,  however,  sets  in  suddenly,  and 
not  gradually,  as  in  weakness  from  general  constitutional  causes. 
Moreover,  the  abdominal  symptoms  are  rarely  wanting,  and  there 
is  more  or  less  confusion  of  mind.  Due  attention  to  these  circum- 
stances will  prevent  mistake ;  but  the  greatest  safeguard  against 
error  is  to  be  aware  that  the  disease  assumes  at  times  a  latent  form, 
and  to  examine  every  case  of  sudden  debility,  to  see  if  under  its 
mask  are  hidden  the  features  of  typhoid  fever. 

Typhoid  Conditions. — ISTo  blunder  is  more  common  than  to  mis- 
construe into  typhoid  fever  a  typhoid  condition  of  the  system. 
We  may  find  this  condition  in  many  different  complaints,  both 
acute  and  chronic ;  but  more  especially  are  purulent  infection, 
some  forms  of  pneumonia,  dysentery,  and  erysipelas  attended  with 
delirium,  drowsiness,  dry,  brown  tongue,  and  extreme  prostration, 
— in  one  word,  with  a  typhoid  state. 

Yet  a  typhoid  state  is  not  typhoid  fever;  it  is  simply  a  low 
condition  of  the  system  which  may  be  present  in  many  dissimilar 
maladies,  and  which  is  present  in  its  most  perfect  form  in  typhoid 
fever.  But  in  this  complaint  we  have  other  signs  than  those  of 
vital  depression  :  we  find  joined  to  it  diarrhoea,  tympanites,  epis- 
taxis,  an  eruption,  and  special  manifestations  of  disturbance  of 
the  nervous  system, — all  symptoms  bearing  no  direct  relation  to 
the  adynamia,  and  thus  serving  as  valuable  distinctive  marks. 
An  examination  of  the  urine,  too,  is  often  of  signal  service ;  though 
we  must  not  forget  that  in  grave  cases  albuminuria  to  a  moderate 
.  degree  is  present.  And  there  are  cases  of  Bright's  disease  and 
of  abscess  of  the  kidney  in  which  the  poisoning  of  the  blood 
which  happens  occasions  a  deceptive  likeness  to  typhoid  fever,  so 
deceptive  that  only  a  minute  examination  of  the  urine  can  fully 
explain  the  true  meaning  of  the  symptoms.  The  following  case 
well  illustrates  this ; 


836  MEDICA.L   DIAGNOSIS. 

A  man,  about  forty-five  years  of  age,  was  admitted  into  the 
Philadelphia  Hospital  in  January,  18G3.  He  was  very  prostrate, 
and  hanllv  ahle  to  give  an  aceount  of  himself.  It  was  ascer- 
tained that  he  was  not  a  person  of  intemperate  habits,  and  that  he 
had  been  attending  to  his  work  until  within  two  Aveeks.  He  was 
evidently  stupid,  and,  when  questioned  about  himself,  seemed  to 
have  great  difficulty  in  remembering,  and  in  collecting  his  thoughts. 
He  had  fever ;  a  pulse  above  100 ;  a  dry,  brown  tongue.  The 
heart-sounds  were  feeble,  the  heart  increased  in  size.  The  urine 
was  at  times  turbid,  and  contained  a  slight,  whitish  sediment, 
which  was  not,  however,  examined  with  the  microscope.  His 
mind  wandered  at  night;  the  abdoriien  was  distended  and  in 
parts  slightly  tender ;  several  doubtful  red  spots  were  detected  on 
its  surface.  In  fact,  he  appeared  to  have  almost  every  one  of  the 
more  constant  symptoms  of  typhoid  fever,  except  the  diarrhoea. 
A  few  days  after  his  admission  he  became  comatose,  and  sank. 
The  intestinal  glands  were  found  in  a  healthy  condition  ;  but  both 
kidneys  were  thoroughly  disorganized  and  filled  with  })us. 

What  exactly  produces  the  typhoid  state  it  is  difficult  to  say. 
Milner  Fothcro-ill*  connects  it  with  tissue-waste  without  in- 
creased  renal  activity,  and  with  the  accumulation  in  the  blood 
of  the  products  of  the  tissue-waste. 

Enteritis. — The  great  difference  between  enteritis  and  typhoid 
fever  consists  in  this  :  in  enteritis  the  inflammation  of  the  intes- 
tine constitutes  the  disease ;  in  typ)hoid  fever  the  irritation  of  the 
intestine  and  morbid  alteration  of  its  glands  are  merely  elements 
of  the  disease.  In  enteritis  there  are  no  symptoms  other  than 
those  referable  to  the  inflamed  intestine.  We  find  no  great  prostra- 
tion ;  no  mental  wandering ;  no  enlargement  of  the  spleen ;  no  rose- 
spots  ;  no  signs  of  abnormal  processes  due  to  a  typhoid  dyscrasia. 
The  disorder,  too,  gives  rise  to  much  more  abdominal  pain,  and 
is  of  shorter  duration.  In  certain  rare  cases  the  follicles  of  the 
intestines  are  inflamed  and  swollen,  and  the  attending  febrile 
malady  may  closely  simulate  typhoid  fever,  without,  however,  its 
characteristic  intestinal  lesions,  or  eruption,  though  with  consider- 
able diarrhoea  and  swelling  of  the  spleen. f   Again,  I  have  known 

*  Edinburgh  Medical  Journal,  September,  1873. 

f  Cazalis  and  Kenaut,  Archives  de  Physiologic,  1873. 


FEVERS.  837 

fsBcal  accumulations  in  the  intestine  produce  and  keep  up  diarrhcea 
and  continued  fever  of  several  weeks'  duration  very  similar  to  that 
of  typhoid,  and  ceasing  only  when  the  large  fiecal  masses  were 
voided.  The  absence  of  eruption,  of  cerebral  symptoms,  and  of 
enlargement  of  the  spleen  proved  the  points  on  which  the  correct 
diagnosis  of  the  non-existence  of  typhoid  fever  was  based. 

Peritonitis. — The  same  remarks  apply  to  peritoneal  inflamma- 
tion. Here,  moreover,  the  expression  of  the  face,  the  consti])ation, 
and  the  great  abdominal  tenderness  serve  as  marks  of  discrimina- 
tion. But  we  must  not  forget  that  acute  peritonitis  may  appear 
in  the  course  of  typhoid  fever.  Generally  this  untoward  event 
happens  at  a  late  period  of  the  disease,  and  after  the  patient  has 
been  under  observation  for  some  time;  we  are  then  at  no  loss  to 
understand  the  meaning  of  the  spreading  tenderness,  the  rapid, 
small  pulse,  the  marked  tympanitic  distention,  the  sweats,  the 
nausea  and  vomiting,  the  collapse,  and  the  pinched  features.  But 
the  accident  may  occur  in  cases  which  we  have  not  previously  seen, 
or  in  which  the  affection  has  run  so  latent  a  course  as  hardly  to 
have  attracted  even  the  patient's  attention.  The  cause  of  the 
peritonitis  is  then  commonly  first  revealed  by  the  autopsy,  which 
shows  actual  perforation  of  the  intestinal  walls,  in  consequence 
of  ulceration  of  a  solitary  or  an  agminated  gland.  Whenever, 
indeed,  in  typhoid  fever  the  signs  of  peritonitis  can  be  clearly 
traced,  the  exciting  cause  of  the  inflammation  may  be  announced 
to  be  perforation ;  for  the  evidence  on  which  it  has  been  assumed 
that  peritoneal  inflammation  may  take  place  without  the  giving 
way  of  the  intestine  is  not  so  positive  as  to  cause  us  to  abandon 
this  diagnostic  rule. 

Meningitis.  —  Typhoid  fever  has  some  symptoms  in  common 
with  inflammation  of  the  brain ;  but  the  signs  of  difference  have 
been  fully  discussed  in  connection  with  acute  meningitis,  and  need 
not  here  be  examined.  And  in  rare  cases  we  really  have  menin- 
gitis as  a  complication  of  typhoid,  showing  small  pupils,  vomit- 
ing, and  rigid  neck.  The  distinction  from  epidemic  cerebro- 
spinal meningitis  we  shall  presently  trace. 

Ulcerative  Endocarditis. — In  some  cases  the  differential  diag- 
nosis between  this  and  typhoid  fever  becomes  of  great  difficulty, 
especially  if  the  case  be  not  seen  until  the  endocarditis  has  led  to 
delirium  and  the  symptoms  of  collapse.     Recurring  chills  with 


838  MEDICAL    DIAQ>'OSIS. 

high  temperature  and  sweats,  as  in  malarial  fever,  great  rapidity 
of  pulse,  with  sudden  changes  and  marked  irregularity,  a  gen- 
erally-diifused  roseolous  eruption,  and  the  signs  of  the  cardiac 
lesion,  form  the  most  trustworthy  points  of  distinction. 

Acute  Pidmonarij  Affections. — In  the  majority  of  cases  of  typhoid 
fever  we  find  cough ,  dependent  upon  an  aifection  of  the  bronchial 
tubes.  The  bronchial  affection  gives  rise  to  extreme  loudness  of 
the  rales,  with  a  cough  disproportionately  slight ;  sometimes,  too, 
owing  to  the  blood  gravitating  to  the  most  dependent  portions 
of  the  lungs,  the  resonance  over  the  posterior  part  of  the  chest  is 
impaired.  From  these  phenomena,  added  to  the  abdominal  and 
cerebral  symptoms  of  the  fever,  there  is  no  difficulty  in  discrimi- 
nating between  idiopathic  bronchitis  and  typhoid  fever.  Nay, 
even  before  the  symptoms  of  the  febrile  malady  arc  clearly  de- 
fined, w^e  may  suspect  the  true  explanation  of  the  rales  from  the 
coexisting  extreme  vital  depression. 

Not  unfrcquently  we  find  a  dry  pleurisy  combined  with  the 
bronchitis,  and  in  some  cases,  not  in  many,  the  cough  is  asso- 
ciated with  exudation  into  the  pulmonary  structure.  Now,  it 
may  be  extremely  difficult  to  distinguish  a  pulmonic  lesion  of 
this  kind  from  inflammation  of  the  lung  setting  in  amid  signs 
of  prostration,  until  the  appearance  of  the  eruption  and  of  the 
abdominal  symptoms  solves  the  difficulty.  Generally,  however, 
it  is  not  a  matter  of  much  doubt,  as  the  condensation  of  the  lung 
in  typhoid  fever  does  not  occur  early  in  the  disease, — not,  in  fact, 
until  the  symptoms  of  the  fever  are  clearly  developed.  Occasion- 
ally a  cough  remains  after  the  febrile  symptoms  have  begun  to 
decline  and  the  mind  is  regaining  its  clearness.  The  cough  in- 
creases in  severity,  and  the  patient  soon  loses  the  strength  he  may 
have  acquired.  On  listening  to  the  chest,  we  find  scattered  over 
both  lungs  many  fine,  dry  and  moist  sounds.  The  percussion 
note  is  here  and  there  dull ;  the  expectoration  is  jsrofuse ;  there 
are  dyspnoea  and  excessive  sweating.  Here  is  a  group  of  signs 
bespeaking  acute  tubercular  phthisis.  The  further  progress  of  the 
disease  reveals  its  nature  more  and  more  distinctly.  On  the  other 
hand,  we  may  observe  acute  phthisis  with  most  of  the  symptoms 
of  typhoid  fever  without  that  affection  being  before  us  ;  even  the 
delirium,  the  stupor,  and  the  enlargement  of  the  spleen  may  be 
present ;  but  the  eruption  never  is,  and  the  diarrhosa  rarely.     In 


FEVEES.  839 

general  acute  mlliaiy  tuberculo.sis  the  similarity  is  even  greater, 
and  diarrhoea  is  not  uncommon.  Tubercle-bacilli  have  been  de- 
tected in  the  urine  and  in  the  blood,  and,  if  present,  enable  us  to 
make  a  positive  diagnosis. 

In  concluding  the  subject  of  typhoid  fever  it  will  be  proper 
to  notice  those  forms  of  the  affection  which  run  their  course  in 
a  diiferent  manner  from  that  ordinarily  pursued  by  the  malady, 
— the  mild  typhoid  and  the  abortive  typhoid.  The  former  has 
usually  a  gradual  beginning,  and  the  disease  throughout  remains 
mild ;  its  duration  may  be,  however,  the  same  as,  or  even  longer 
than,  that  of  ordinary  typhoid,  or  it  may  be  considerably  shorter, 
— in  fact,  an  abortive  typhoid,  the  variety  of  typhoid  to  which  of 
late  years  Jiirgensen  especially  has  directed  attention.*  Yet  the 
abortive  type  is  not  always  mild  :  cases  are  mentioned  f  in  which 
the  temperature  rose  to  106°,  but  in  which  the  duration  of  the 
fever  was  only  from  seven  to  twelve  days.  Indeed,  it  is  the  short 
duration  that  is  characteristic  of  abortive  typhoid.  As  a  rule,  it 
begins  suddenly,  and  the  temperature  reaches  its  highest  point  on 
the  second  or  third  day.  It  often  does  not  exceed  104°,  and  it 
stays  at,  or  near,  the  height  it  has  so  speedily  attained  for  the 
greater  part  of  the  duration  of  the  fever,  and  then  remissions 
show  themselves,  and  there  is  a  gradual  return  to  a  healthy 
standard,  much  in  the  same  way  as  at  the  end  of  ordinary  typhoid 
fever ;  or  the  changes  are  so  marked  and  rapid  that  the  deferves- 
cence is  accomplished  in  a  few  days.  The  symptoms  of  typhoid 
fever  are  all  met  with  in  the  abortive  malady,  though  they  are 
not  present  with  the  same  constancy  ;  tenderness  in  the  right  iliac 
fossa  is  the  most  frequent ;  enlargement  of  the  spleen  and  the 
rose-colored  spots  are  very  usual ;  diarrhcea  is  often  wanting. 
The  disease  terminates  in  sixteen  days  or  less  ;  but  there  is  great 
proneness  to  relapses.     It  is  not  apt  to  be  a  fatal  affection. 

Typhus  Fever. — This  is  a  highly-contagious  malady,  almost 
always  met  with  in  an  epidemic  form,  and  generally  among  those 
whose  systems  are  depressed.  It  prevails  in  jails  and  camps, 
among  crowded  populations,  or  in  badly-ventilated  localities,  and 
has  no  constant  structural  lesion.     In  this  country  it  is  a  rare 

*  Sainmlung  Klinischer  Vortrage,  No.  61,  1873.    See  also  a  paper  by  Johns- 
ton, Amer.  Journ.  Med.  Sci.,  Oct.  1875. 
t  Liebermeister,  in  Ziemssen's  Cyclopaedia. 


840  MEDICAL    DIAGNOSIS. 

disease.  It  is  cither  prceeck'd  by  a  brief  stage  of  lassitude  and 
dejection,  or  is  iisliered  in  ^\•itll  a  chill  and  pain  in  the  head 
and  back.  The  skin  soon  becomes  dry  and  of  pnngent  heat ;  the 
pulse  rises  much  in  frequency,  and  is  at  iirst  full,  sometimes  even 
tense.  The  patient  lies  in  a  state  of  half-consciousness,  dull, 
drowsy,  weak,  with  evident  signs  of  his  nervous  and  muscular 
system  being  overwhelmed  by  the  influence  of  some  fearfully- 
depressing  poison.  The  face  is  flushed  ;  the  odor  from  the  body 
extremely  unpleasant. 

By  the  fifth  day  all  these  symptoms  are  plainly  marked,  and 
about  this  time  a  coarse,  red,  cutaneous  eruption  makes  its  appear- 
ance. But  it  occasions  no  change  in  the  gravity  of  the  symptoms. 
On  the  contrary,  the  confusion  of  mind  and  the  stupor  increase ; 
the  patient  ^vanders,  picks  at  his  bedclothes,  and  ceases  to  com- 
plain of  the  pain  in  the  head  or  limbs.  The  pulse  is  frequent  and 
feeble ;  the  tongue  dry  and  dark  ;  sordes  collect  on  the  gums  and 
teeth.  The  bowels  remain  as  they  were  at  the  onset, — constipated. 
The  urine  often  comes  away  drop  by  drop,  or,  as  the  bladder 
loses  the  power  of  contracting,  is  retained.  The  case  has  now 
reached  its  height ;  the  signs  of  a  prostrated  nervous  system,  of 
deteriorated  blood,  and  of  utter  loss  of  muscular  strength  either 
begin  to  pass  away,  or  deepen  from  hour  to  hour  and  clearly 
show  the  doom  that  awaits  the  fever-stricken  patient.  From  the 
beginning  of  the  distemper  until  the  unfortunate  issue,  is  rarely 
over  thirteen  days.  If  the  sick  man  can  withstand  the  poison 
until  the  third  week,  he  is  apt  to  throw  it  oif  and  recover ;  but 
it  may  be  so  virulent  as  to  overpower  him  almost  at  the  onset. 

Let  us  examine  some  of  the  symptoms  of  this  pestilential  dis- 
ease in  detail. 

The  2^f^y-^^ognomy  of  typhus  is  peculiar.  The  expression  is 
stupid,  and  coarser  than  in  health.  The  face  wears  a  deep  flush, 
of  a  dusky-red  hue.  The  eye  is  injected,  the  pupil  often  con- 
tracted. The  skin  is  covered  with  a  characteristic  erupiion,  from 
which  the  disease  takes  its  name  of  "  spotted"  or  "  maculated" 
typhus.  The  rash  is  at  first  slightly  elevated  and  usually  much 
like  that  of  measles.  It  is  of  a  dark  tint,  a  "  mulberry  rash," 
and  fades  but  does  not  vanish  on  pressure.  It  makes  its  appear- 
ance from  the  fifth  to  the  seventh  day,  and  is  permanent,  consist- 
ing not  of  successive  eruptions,  but  of  the  same  spots,  which  deepen 


FEVEES.  841 

or  lighten  with  the  changes  in  the  disease,  and  do  not  pass  away 
before  the  fourteenth  day.  Each  spot  thus  lasts  until  recovery  or 
until  death,  and  no  new  ones  show  themselves  after  the  second  or 
third  day  of  the  rash.  They  are  generally  very  numerous  on  the 
trunk  and  the  extremities,  but  are  rarely  observed  upon  the  face. 
Some  are  much  lighter  than  others,  and  thus  a  mottled  aspect  of 
the  skin  is  produced,  on  which  Sir  William  Jenner  *  lays  great 
stress.  Sometimes  the  spots  are  of  purple  color  and  uninfluenced 
by  pressure.  These  petechise  are  the  attendants  of  the  worst  forms 
of  the  malady. 

The  skin  of  a  typhus  fever  patient  is  often  sensitive,  and,  as 
already  stated,  generally  very  hot.  In  some  cases  the  thermometer 
indicates- a  temperature  of  107°,  or  more ;  most  commonly  it  ranges 
above  104°.  The  heat  is  sustained  :  it  does  not  show  the  marked 
differences  between  morning  and  evening  which  are  observed  in 
typhoid  fever,  the  daily  variations  to  the  middle  of  the  second 
Aveek  being  rarely  1  °  Fahr. ;  and  from  that  time  onward  the 
morning  abatement  does  not  amount  to  more  than  about  1.5° 
until  the  defervescence  is  reached.  The  passing  away  of  the  high 
temperature  occurs,  however,  not,  as  in  enteric  fever,  by  grad- 
ual, though  more  and  more  evident,  remissions,  but  suddenly. 
Early  in  or  toward  the  middle  of  the  third  week  the  temperature 
falls  quickly,  and  in  twenty-four  or  thirty-six  hours  a  normal 
standard  is  reached. 

The  cerebral  symptoms  of  typhus  fever  are  never  absent,  al- 
though they  vary  much  both  in  intensity  and  in  character.  In 
some  epidemics  they  constitute  the  prominent  feature  of  many 
cases,  and  dangerous  and  fatal  these  cases  are  apt  to  be.  One  of 
the  most  frequent  proofs  of  the  disturbance  of  the  brain  is  seen 
in  stupor.  The  patient  lies  in  a  heavy  slumber,  occasionally  mut- 
tering some  incoherent  words ;  or  he  is  sleepless,  his  eyes  remain 
wide  open,  he  has  Goma-vigU,  he  takes  no  notice  of  anything 
going  on  around  him.  Either  of  these  states  may  deepen  into 
coma.  In  other  cases  delirium  is  the  most  conspicuous  symptom. 
This  delirium  rarely  sets  in  before  the  end  of  the  first  week.  In 
type  it  is  low  and  muttering,  and  unaccompanied  by  great  rest- 

*  Identity  or  Non-Identity  of  Typhoid  and  Typhus  Fevers,  London,  1850  ; 
and  Medico-Chirurgical  Transactions,  vol.  xxxiii. 


842  MEDICAL    DIAGNOSIS. 

lessnoss ;  or  it  may  be  associated  with  constant  movements  and 
trembling  of  the  limbs,  or  jerking  of  the  tendons, — in  fact,  with 
symptoms  resembling  those  designated  as  hysterical.  Sometimes 
the  mental  wandering  is  active  and  very  persistent.  The  patient 
tosses  a})()ut,  is  constantly  talking,  and  can  hardly  be  restrained 
from  sxettinsi:  out  of  bed.  He  has  illusions  of  hearing:  and  of 
sight ;  his  eyes  are  injected,  the  pupils  often  contracted  ;  there  is 
headache,  with  intolerance  of  light.  Here  we  have  tlie  true  brain 
typhus,  with  its  formidable  cerebral  symptoms  simulating  closely 
those  of  acute  meninr/itis,  and  differing  only  by  their  union  with  a 
cutaneous  eruption,  by  the  dissimilar  aspect  of  the  tongue,  and  by 
the  beat  of  the  pulse,  which  is  rarely  full,  and  never  so  tense  as 
that  of  meningitis.  Then,  the  nervous  excitement  is  accompanied, 
or,  at  all  events,  soon  succeeded,  by  greater  and  more  rapid  pros- 
tration of  strength,  and  is  often  exchanged  far  more  suddenly  for 
coma  than  is  observed  in  the  meningeal  disorder. 

The  headache  which  has  just  been  mentioned  is  a  very  constant 
svmptom:  usually  it  is  most  severe  during  the  first  week,  and 
abates  with  the  appearance  of  the  mental  wandering.  Often  it  is 
accompanied  by  more  or  less  giddiness,  which  increases  with  the 
progress  of  the  disease. 

These  head-symptoms  of  typhus  are,  like  those  of  enteric  fever, 
sometimes  connected  with  a  noisy,  shallow,  and  irregular  respira- 
tion. This  kind  of  breathing  can  be  clearly  traced  to  the  abnormal 
state  of  the  nervous  system,  as  no  signs  of  alteration  in  the  lungs 
coexist.  Often,  as  Flint*  has  pointed  out,  it  is  a  forerunner  of 
fatal  coma.  In  one  case  I  found  the  strange  phenomenon  associ- 
ated with  great  distention  of  the  bladder,  and  subsiding  materially 
after  the  introduction  of  a  catheter. 

The  remarks  with  reference  to  the  cerebral  phenomena  of  typhus 
apply  to  those  instances  in  which  there  is  no  inflammatory  disorder 
within  the  cranium.  But  we  must  not  overlook  the  fact  that  this 
may  ensue.  Such  cases  are  difficult  of  recognition.  The  pulse, 
as  a  rule,  is  slow  and  irregular,  the  pupils  are  contracted,  there  is 
a  frown  on  the  forehead,  and  intense  headache,  sometimes  scream- 
ing. Vomiting  is  not  always  encountered.  We  may  find  with 
these  symptoms  acute  hydrocephalus,  and  the  morbid  appearances 

*  Clinical  Reports  on  Continued  Fever. 


FEVERS.  843 

may  be  confined  chiefly  to  the  base  of  the  brain.*  There  are  other 
symptoms  referable  to  the  nervous  system  which  are  occasionally 
very  marked,  such  as  great  agitation,  rigidity  of  certain  muscles, 
and  convulsions.  •  But  as  regards  the  latter,  the  nervous  system  is 
for  the  most  part  only  secondarily  disturbed,  for  the  convulsions 
are  generally  of  ursemic  origin. 

The  pulse,  after  the  disease  is  fully  developed,  is  generally  rapid, 
and  either  of  moderate  volume  or  feeble.  As  the  disorder  ad- 
vances, and  the  strength  becomes  more  and  more  impaired,  it 
rises  in  frequency,  while  it  diminishes  in  force.  As  convalescence 
is  established,  it  falls ;  if  it  remain  frequent,  this  is  generally 
indicative  of  some  concealed  visceral  disorder,  often  of  a  disease 
of  the  lungs.  It  does  not  always  correspond  closely  with  the 
condition  of  the  heart,  so  far,  at  least,  as  this  is  revealed  by  the 
impulse.  The  beat  may  be  excited  and  violent,  while  the  pulse 
is  very  weak.  Often  the  cardiac  impulse  undergoes  a  singular 
diminution,  and  with  its  change  the  first  sound  becomes  enfeebled ; 
in  fact,  it  is  sometimes  almost  lost,  and  only  very  gradually  re- 
gains its  natural  tone.  Occasionally,  at  the  height  of  the  disease, 
it  is  replaced  by  a  soft,  systolic  murmur ;  a  sign  of  the  depraved 
state  of  the  blood. 

The  urine  is  generally  high-colored  at  first,  but  may  become 
very  pale  as  convalescence  sets  in,  depositing  an  abundance  of 
urates  and  phosphates.  There  is  an  absence  of  the  chlorides,  or 
they  are  reduced  to  a  trace.  The  urea,  as  ascertained  by  an 
analysis  of  Parkes  t  in  a  case  in  which  no  medicine  was  given, 
is  increased,  and  its  augmented  excretion  is  remarkably  regular 
during  the  height  of  the  malady.  During  convalescence  the  urea 
sinks  below  the  normal  standard,  and  then  gradually  rises  to  it. 
The  water  passed  is  lessened,  and  it  would  appear  to  be  retained 
in  the  system.  The  urine  is  apt  to  contain  a  large  amount  of 
uric  acid,  and  to  preserve  its  acidity.  In  eight  out  of  twenty- 
one  cases  that  I  examined  during  an  epidemic,!  it  contained  albu- 
men, and  this  ingredient  was  present  only  in  the  severer  cases. 
In  some  instances  the  microscope  exhibits  in  the  deposit,  besides 


*  Kennedy,  Dublin  Quarterly  Journal,  Feb.  1867. 

■j-  The  Urine  in  Disease,  p.  258. 

+  Amer.  Jouiui.  Med.  Sci.,  Jan.  1866. 


844  MEDICAL   DIAGNOSIS. 

the  salts  of  the  urine,  renal  as  well  as  vesieal  epitlielium,  and 
tube-casts,  either  finely  granular  or  hyaline,  or  epithelial.  Much 
the  same  condition  of  urine  is  also  found  in  typhoid  fever. 
But  the  pigment  Avhieh  in  typhus  fever  was  detected  by  Parkes 
throughout  only  in  small  amounts,  has  in  typhoid  fever  been 
found  to  be  immensely  increased. 

The  complicalioi.^  encountered  during  the  course  of  the  fever, 
or  during  convalescence,  are  much  the  same  as  those  of  typhoid 
fever,  although  they  do  not  in  the  two  diseases  occur  with  equal 
frequency.  We  meet  with  abscesses,  with  large  sloughs  on  tlie 
trunk  and  extremities,  or  with  gangrene  of  the  extremities,*  with 
milk-leg,  with  erysipelas,  with  inflammation  of  the  parotid  gland, 
with  oedema  of  the  glottis,  and  with  pulmonary  complaints.  The 
latter  are  very  common,  and  mostly  very  alarming.  Sometimes 
they  consist  merely  in  affections  of  the  larger  bronchial  tubes ; 
but  very  often  we  have  to  deal  with  a  dangerous  capillary  form 
of  bronchitis,  beginning  insidiously,  not  attended  with  much 
cough,  and  easily  overlooked.  A  coarse  crepitation  or  fine  bub- 
bling sounds  arc  heard  over  the  whole  chest,  and  the  res])iration 
is  hurried.  At  times,  instead  of  these  signs,  or  associated  with 
them,  may  be  noticed  duhiess  on  percussion  and  bronchial  respira- 
tion over  the  lower  lobes  of  the  lungs,  depending  u])on  conges- 
tion, with  consolidation  more  or  less  perfect,  of  the  pulmonary 
tissue.  Here  is  one  of  the  worst  of  all  the  complications, — a  low 
form  of  pneumonia.  It  must,  however,  not  be  confounded  with 
the  so-called  'pneumotyphus,-\  in  which  the  manifestations  of  pneu- 
monia appear  early  and  become  later  complicated  with  those  of 
a  typh- fever,  though  generally  of  typhoid  and  not  of  typhus. 
During  the  last  stages  of  typhus  fever,  or  after  convalescence  has 
set  in,  acute  tubercular  deposits  occasionally  develop  themselves 
in  the  lungs  with  the  same  symptoms  as  during  or  subsequent 
to  typhoid  fever.  One  of  the  most  significant  signs  of  this 
untoward  event  is  the  utter  want  of  response  of  the  system  to 
stimulants  and  tonics. 

To  discuss  now  the  differential  diagnosis  of  typhus  fever.  We 
find  various  maladies  resembling  it,  but  none  so  closely  as  typhoid 


*  Estliinder,  quoted  in  Amer.  Journ.  Med.  Sci.,  July,  1871. 
t  Wagner,  Archiv  fur  Klin.  Med.,  Aug.  1884. 


FEVERS. 


845 


fever.    The  subjoined  table  shows  both  their  similarities  and  their 
differences  : 


Typhoid. 

Age  generallj'  from  eighteen  to  thirty- 
five. 

Not  contagious,  or  but  feebly  so ; 
often  sporadic. 

Attack  generally  insidious. 

Duration  fully  three  weeks  ;  very 
frequently  much  longer. 

Death  hardly  ever  before  end  of  sec- 
ond week  ;  more  generally  in,  or 
after,  third  week. 

Cei'ebral  symptoms  come  on  gradu- 
ally ;  last  longer. 


Great  emaciation. 

Face  pale,  or  flush  confined  to  cheeks. 

Skin  hot,  sometimes  covered  with  acid 

perspiration. 
Characteristic  temperature-record, 

chiefly   influenced   by   the   changes 

in  the  glandular  intestinal  lesion. 
Abdominal   symptoms,  such   as  diar- 

rhcea,  tympanites ;    intestinal   hem- 

orrhao;e  not  unusual. 


Epistaxis  common. 
Bronchitis  and  pleurisy. 


Eruption  light  red,  and  not  on  ex- 
tremities. 

Post-mortem  appearances  are:  mor- 
bid state  of  Peyer's  patches ;  en- 
largement of  mesenteric  glands ; 
ulceration  of  mucous  coat  of  intes- 
tine ;  enlargement  and  softening  of 

■    spleen  ;  ulceration  of  phar^-nx. 


Typhus. 

At  all  ages ;  often  in  persons  beyond 
middle  life. 

Highly  contagious ;  generally  epi- 
demic. 

Attack  generally  sudden. 

Duration  somewhat  shorter  ;  often  not 
prolonged  beyond  second  week. 

Death  not  unfrequently  at  end  of  first 
week,  and  often  before  conclusion 
of  second. 

Delirium  or  decided  stupor  comes  on 
soon,  sometimes  almost  from  the 
onset ;  headache  has  appeared  and 
disappeared  by  about  the  tenth  day. 

Less  emaciation  ;  greater  prostration. 

Face  deeply  flushed,  of  dusky  hue ; 
eye  injected. 

Skin  of  pungent  heat ;  sometimes 
emitting  an  ammoniacal  odor. 

Temperature-record  more  that  of  a 
continuous  fever ;  for  the  most  part 
sudden  and  rapid  defervescence. 

No  abdominal  symptoms  ;  bowels  con- 
stipated ;  meteorism  rare ;  intes- 
tinal hemorrhage  of  extreme  rarity  ; 
sometimes  acute  dj'sentery  during 
convalescence,  or  as  a  sequel. 

No  epistaxis. 

Pneumonia,  or,  at  all  events,  more 
marked  intense  congestion  of  the 
lungs,  and  bronchitis  of  finer  tubes. 

Eruption  darker  color,  and  all  over 
body. 

No  constant  post-mortem  appear- 
ances ;  the  most  frequent  are  the 
dark-colored,  liquid  state  of  the 
blood,  and  enlargement  of  spleen. 
Softening  of  the  heart  is  more 
common  in  typhus  than  in  typhoid. 
There  are  no  intestinal  lesions. 


The  points  of  contrast  between  the  two  affections  are  here  so 
manifest  that  it  would  seem  impossible  to  confound  them.  Yet 
it  cannot  be  denied  that  occasionally  the  symptoms  of  the  two 


846  MEDICAL   DIAGNOSIS. 

diseases  are  strano-cly  blended  or  interchanged.  Thus,  we  may 
have  consti})ati()n  in  ty})li()id,  and  diarrhoea  in  tyj^hus,  or  the 
eruption  may  be  curiously  mixed.     For  instance  : 

A  boy,  sixteen  years  of  age,  was  received  into  the  Philadelphia 
Hospital,  Avith  evident  signs  of  a  beginning  fever  of  a  low  type. 
A  day  or  two  after  his  admission,  and  corresponding,  as  nearly  as 
could  be  ascertained,  to  the  fifth  day  of  the  disease,  an  eruption 
showed  itself  all  over  the  body.  It  was  dark-colored,  petechial 
in  its  aspect,  and  did  not  disappear  on  pressure.  Associated  with 
it  were  drowsiness  and  constipation.  In  a  few  days  more,  how- 
ever, the  symptoms  changed.  The  dark  eruption  faded,  and  rose- 
colored  spots  were  perceptible  on  the  chest  and  abdomen  ;  diarrhoea 
set  in,  and  the  fever  ran  its  course  to  a  favorable  termination  with 
the  character  of  typhoid,  just  as  at  the  onset  it  had  assumed  the 
character  of  typhus. 

Besides  typhoid  fever,  typhus  may  be  confounded  with  menin- 
gitis, with  inflammation  of  the  lungs,  with  measles,  with  small- 
pox, and  with  the  plague.  The  distinctive  marks  between  the 
first  t\vo  and  typhus  fever  have  been  rendered  apparent  while 
discussing  the  cerebral  and  pulmonary  complications  of  the  latter 
malady.  I  shall  here  only  dwell  again  upon  the  great  value  of 
the  eruption  in  a  diagnostic  point  of  view.  The  symptoms  which 
approximate  measles,  smallpox,  and  yellow  fever  to  tyj^hus  will 
be  analyzed  in  connection  with  these  affections.  One  word  here 
as  to  its  difference  from  the  plague. 

This  pestilent  disease,  which  during  several  centuries  left  almost 
annually  its  deep  indent  upon  the  human  race,  is  hardly  known 
to  any  but  Russian  physicians  at  present,  save  by  description.  And 
the  descriptions  leave  on  the  mind  the  impression  of  an  exposition 
of  a  familiar  malady  ;  for  the  authors  who  have  most  carefully  de- 
lineated its  traits  have  produced  a  picture  which,  with  very  slight 
changes,  may  be  suited  to  a  representation  of  epidemics  of  typhus 
fever.  Thus,  we  read  of  a  highly-contagious  fever  setting  in  sud- 
denly, attended  with  constipation,  with  a  rapid,  feeble  pulse,  with 
dizziness  and  delirium,  with  injected  eyes,  with  a  dry  tongue,  with 
noises  in  the  ears  and  deafness,  with  defective  urinary  secretion, 
with  starting  of  the  tendons,  with  watchfulness  or  stupor,  and 
with  red  patches  and  purple  spots  scattered  over  the  surface  of  the 
body.     The  features  which  the  plague  does  not  share  with  typhus 


FEVERS.  847 

are  nausea  and  vomiting,  pale  face,  an  alarmed,  desjiairing  loolc 
of  the  countenance,  haemoptysis,  and,  above  all,  the  buboes  and 
carbuncles  in  different  parts  of  the  body,  and  the  clearing  mind 
when  they  happen.  Moreover,  the  disease  is  of  much  shorter 
duration.  Death  generally  takes  place  between  the  third  and  the 
fifth  day,  or  convalescence  sets  in  on  the  sixth  or  the  seventh  day, 
or  early  in  the  second  week.  It  may,  however,  be  protracted  by 
the  long-continuing  suppuration  of  the  buboes. 

In  very  severe  cases  death  takes  place  in  forty-eight  hours. 
These  cases  are  apt  to  be  associated  with  but  slight  fever  and  with 
clear  intelligence.* 

The  relations  of  typhus  fever  to  cerebro-spinal  fever  will  be  best 
discussed  with  the  latter  disease. 

Cerebro-spinal  Fever. — This  disease  is  also  known  as  cere- 
bro-spinal typhus,  as  epidemic  meningitis,  and  as  epidemic  cerebro- 
spinal meningitis,  and  is  the  aifection  which  has  been  called  in  this 
country  spotted  fever.  It  was  formerly  very  prevalent  in  portions 
of  the  United  States,  as  we  judge  by  the  descriptions  of  Hale, 
Gallup,  North,  and  Ames ;  but  the  present  generation  of  i)hysi- 
cians  had  little  knowledge  of  it  until  about  simultaneously  with 
the  severe  epidemic  in  Germany  in  1863  and  1864  it  invaded  this 
country  and  committed  great  ravages,  especially  in  some  of  the 
New-England  States,  in  New  York,  and  in  Pennsylvania.  Since 
that  time  it  has  become  naturalized  here,  as  Ziemssen  states  to  be 
also  the  case  in  Germany. f 

Cerebro-spinal  meningitis  does  not  always  present  exactly  the 
same  symptoms.  These  vary  somewhat  according  to  the  struc- 
tures which  bear  the  brunt  of  the  disease.  Usually,  however, 
marked  cerebro-spinal  phenomena  preponderate;  in  some  in- 
stances the  evidences  of  pulmonary  embarrassment  or  of  blood 
deterioration  are  very  prominent.  Again,  the  signs  of  spinal 
disturbance  may  prevail  over  those  of  the  cerebral,  or  the  reverse. 

The  disease  may  be  gradual  in  its  approach,  feelings  of  chil- 
liness, succeeded  by  headache,  by  tenderness  at  the  nape  of  the 
neck,  by  nausea,  and  by  j)ain  in  the  back  and  joints,  preceding  its 
full  development.      Generally  its  onset  is  sudden ;  a  violent  chill 

*  Hirsch  and  Sommerbrodt's   report  on  tlie  epidemic  in  Astrachan  in  tlie 
winter  of  1878-79,  Berlin,  1880. 
f  Cyclopaedia  of  the  Practice  of  Medicine,  vol.  ii.,  1875.  *    . 


848  MEDICAL    DIAGNOSIS. 

is  quickly  followed  by  intense  headache,  vomiting,  and  extreme 
prostration.  However  the  beginning,  the  disease  iisually  soon 
reaches  its  full  development.  The  excruciating  headache  is  as- 
sociated with  vertigo,  and  often  Avith  delirium  and  stupor.  The 
headache  may  remit,  but  docs  not  cease  during  the  attack.  An- 
other symptom  of  the  fully-developed  disease  is  stiffness  of  the 
deep  muscles  of  the  neck,  so  that  tiie  patient  cannot  bcMid  tlie  head 
forward ;  and  the  stiffness  may  pass  into  marked  contraction,  and 
the  head  be  thrown  backward  and  rigidly  fixed.  The  contraction 
of  the  muscles  may  extend  along  the  spine,  which  frequently  is 
painful,  not  specially  to  the  touch,  but  on  movement  of  any  kind  ; 
sometimes,  moreover,  severe  spontaneous  pain  occurs.  There  are 
also  pain  at  the  nape  of  the  neck,  and  in  the  loins  and  shooting 
to  the  lower  extremities,  and  pain  at  the  epigastrium,  and  a  feel- 
ing of  contraction  of  the  chest.  The  face  has  a  fixed  or  suffering 
expression  ;  the  patient  is  extremely  restless ;  he  trembles ;  talks 
incoherently ;  when  spoken  to,  does  not  appear  to  hear ;  his  pupils 
are  generally  dilated,  and  there  may  be  dimness  of  sight,  or  double 
vision.  The  skin  is  dry,  generally  very  sensitive,  or  in  some  parts 
the  sensibility  is  increased,  in  others  diminished,  and  the  cutaneous 
surface  is  frequently  spotted  with  a  red  eruption,  erythematous  and 
roseolous, — an  eruption  which  often  becomes  brownish,  and  then 
for  the  most  part  rapidly  petechial,  and  wholly  uninfluenced  by 
pressure  ;  or  the  purple  spots  may  be  seen  from  the  start.  Vesi- 
cles, too,  are  apt  to  appear  on  the  lips.  They  show  themselves 
from  the  third  to  the  sixth  day  of  the  disease,  while  the  eruption 
is  seen  on  the  first  day,  or  may  at  all  events  be  detected  by  the 
third  day.  The  pulse  at  first  is  either  natural  or  slow ;  but  it 
becomes  rather  frequent  and  irregular,  and  commonly  remains 
accelerated  throughout  the  disease,  showing  extraordinary  varia- 
tions in  a  few  hours.  The  tongue  is  moist  or  dry,  and  brown ;  the 
breathing  often  hurried  and  shallow ;  and  the  urine  I  have  often 
noticed  to  contain  large  quantities  of  urates  and  to  be  slightly 
albuminous.  The  bowels  are  at  the  outset  constipated,  but  as  the 
malady  advances  they  become  relaxed.  Tliere  is  usually  persistent 
irritability  of  the  stomacli,  with  great  thirst,  and  s]Wsmodic  con- 
tractions or  convulsive  movements  in  the  muscles  of  the  extremi- 
ties. AVith  these  symptoms,  to  which  those  of  exhaustion  become 
plainly  added,  the  disorder  progresses  to  its  close,  presenting  now 


FEVERS.  849 

and  then  stmnge  and  delusive  remissions,  soon  followed  by  distinct 
exacerbations.  In  fortunate  instances  the  morbid  ]:)hcnomena 
gradually  lose  their  violence,  and  the  patient,  greatly  emaciated, 
enters  upon  a  tedious  convalescence. 

But  though  these  are  the  symptoms  which  frequently  recur  in 
epidemics,  yet,  as  already  indicated,  they  cannot  always  l)e  taken 
as  the  standard  expression  of  the  disease.  Most  of  them  were 
observed  in  the  formidable  examples  of  the  malady  which  have 
of  late  years  been  encountered  in  this  country ;  and  they  have 
also  been  met  with  in  the  epidemic  cerebro-spinal  meningitis  prev- 
alent in  Germany.  As  regards  one  of  these  epidemics,  we  are 
told  by  Wunderlich*  that  the  spleen,  early  in  the  affection,  en- 
larges, but  does  not  continue  tumefied  ;  and  that  the  temperature 
reaches  106°  to  108°,  or  even  higher,  without  there  being  a  pro- 
portionate rise  in  the  pulse ;  or  this  may  become  frequent  without 
a  corresponding  increase  in  the  temperature,  which,  moreover,  is 
not  sustained  at  tlie  same  height.  And,  whether  the  pulse  be 
rapid  or  slow,  the  force  of  the  heart's  impulse  is  at  times  found 
to  be  singularly  augmented.  The  irregularity  of  the  temperature 
has  also  been  noticed  by  Ziemssen,t  and  was  a  common  feature 
in  our  epidemics.  The  high  temperatures  are  often  interrupted 
by  long-continued  normal  temperatures ;  indeed,  we  frequently 
meet  with  cases  in  which  at  no  time  much  elevation  of  tempera- 
ture is  present. 

The  duration  of  the  malady  is  very  various.  Patients  may 
become  rapidly  comatose,  and  die  within  twelve  hours,  before  any 
distinctly  febrile  action  has  begun ;  or  may  sink  in  a  few  days ; 
or,  on  the  other  hand,  the  complaint  may  pursue  a  very  chronic 
course,  lasting  for  weeks,  and  during  this  time  deafness  and  blind- 
ness, convulsions,  retention  of  urine,  and  local  palsies — though 
these  are  unusual — may  be  prominent  phenomena. 

Of  the  cause  of  the  formidable  disease  we  know  little.  It  is 
not  a  malarial  disease ;  for,  though  occasionally  there  is  a  singu- 
lar intermission  or  remission  in  the  symptoms,  there  is  no  regu- 
larity in  this  respect.       The   temperature-record,  even  of  these 


■*  Archiv  der  Heilkunde,  No.  III.,  1865,  quoted  in  Amer.  Journ.  Med.  Sci. 
for  Oct.  1865. 
t  Op.  cit. 

54 


850  MEDICAL,    DIAGNOSIS. 

ap})arontly  malarial  eases,  is  different,  being-  irreoular;  and  the 
ati'eetion  is  nnyielding  to  quinine.  Many  look  upon  it  as  modi- 
fied typhus ;  and  certainly  the  disorder  occurs  epidemically  under 
much  the  same  circumstances  as  typhus,  and  is  a  general  disease, 
not  merely  an  inflanmiation.  But,  though  kindred  to  typhus,  a 
fever  of  typhous  type,  it  is  due  to  a  different  poison,  and  differs 
broadly  from  typhus  in  being  far  less  contagious,  if  indeed  it  can 
be  regarded  as  contagious  at  all,  and  by  the  inflammatory  lesions 
found  in  the  brain  and  spinal  cord.  To  the  diagnostic  ditrerences 
I  shall  presently  refer. 

Corel) ro-spinal  meningitis  attacks  cliildrcn  very  frequently.  It 
is  more  common  in  winter  and  in  spring  than  in  summer ;  though 
I  have  seen  it  in  summer.  It  is  an  affection  very  familiar  to 
military  surgeons  ;  it  seizes  on  recruits  who  have  been  sul)jected  to 
unaccustomed  fatigue  or  have  been  huddled  together  in  unhealthy 
barracks  or  camps. 

To  determine  the  diagnosis  is  ordinarily  not  difficult:  the  sud- 
den onset  of  the  malady  and  its  epidemic  character  are  safeguards 
against  error.  The  protracted  cases  simulate  typhoid  fever.  They 
resemble  it  in  its  long  duration,  in  several  of  the  cerebral  symp- 
toms, and  in  the  occurrence  of  an  eruption,  and  sometimes  of 
diarrhoea.  They  differ  from  it  in  the  more  abrupt  invasion,  or 
rather  in  the  short  time  in  which  the  disease  reaches  an  alarming 
aspect ;  and  in  the  early  stages  the  violent  headache,  the  constipa- 
tion, the  constant  vomiting,  the  slow  or  normal  pulse,  and  the  cool 
or  but  slightly  heated  skin,  are  unlike  the  signs  of  enteric  fever. 
In  those  cases  in  which  an  eruption  appears,  it  is  noticed,  at  latest, 
by  the  third  or  fourth  day,  not  at  the  end  of  a  week,  as  in  typhoid 
fever;  nor  is  the  rash,  save  in  extremely  rare  instances,  rose- 
colored.  Later  in  the  malady  the  traits  of  distinction  become 
broader  and  broader.  The  prominence  of  the  abdominal  symp- 
toms in  the  one  disorder ;  the  continued  violent  headache,  the 
fixed  spinal  pain,  the  hyperresthesia,  the  facial  herpes,  the  severe 
twitchings  or  the  tetanic  rigidity  of  the  muscles,  and  the  absence 
of  marked  enlargement  of  the  spleen,  in  the  other, — are  signs  the 
import  of  which  is  not  easily  overlooked. 

The  suddenness  with  which  the  morbid  phenomena  occasionally 
develop  themselves,  and  the  lulls  that  take  place  in  the  course  of 
the  affection,  may  cause  it  to  be  mistaken  for  the  cerebral  variety 


FEVERS.  851 

of  congestive  fever.  But  the  remissions  are  not  so  marked  as  in 
this  pernicious  malady,  nor  are  the  exacerbations  preceded  by  a 
long,  violent  chill.  Moreover,  the  temperature-record  is  differ- 
ent, and  congestive  fever  does  not  begin  with  congestive  symp- 
toms, but  the  first  attack  is  like  that  of  an  ordinary  intermittent 
or  remittent :  hence  we  have  the  history  of  the  case  to  instruct  us. 

From  tetanus  cerebro-spinal  meningitis  may  be  distinguished 
by  its  epidemic  prevalence,  and  by  the  signs  of  mental  disturbance, 
which  are  very  slight  or  wholly  wanting  in  the  former  disorder. 
Generally,  too,  the  sudden  and  painful  spasms,  aggravating  the 
tetanoid  contractions,  and  the  cognizance  of  the  exciting  cause 
of  the  tetanic  convulsions,  such  as  their  following  wounds  or 
punctures,  aid  in  interpreting  their  meaning. 

How  can  we  discriminate  between  inflammation  of  the  meninges 
of  the  cord  and  epidemic  cerebro-spinal  meningitis  ?  Thus :  in 
pure  spinal  meningitis,  as  in  myelitis,  mental  symptoms  are  ab- 
sent ;  their  presence  in  cerebro-spinal  fever  constitutes  one  of  the 
marked  features  of  the  disease.  The  history  of  the  case  in  the 
former  malady  points  to  cold  and  exposure  or  to  syphilis.  Clonic 
spasms  of  the  extremities  are  more  common ;  persistent  rigidity  of 
the  muscles  is  a  less  striking  peculiarity.     We  find  no  eruption. 

Tubercular  meningitis  is  distinguished  by  the  much  more  in- 
sidious beginning,  the  much  more  protracted  course,  the  absence 
of  eruption,  and  usually  of  marked  stiffness  of  the  neck,  the  va- 
riations in  the  pulse  according  to  the  stage  of  the  disease,  the 
irregular  breathing,  and  the  history  of  a  scrofulous  or  tubercular 
taint. 

Sporadic  cerebro-spinal  meningitis  is  a  rare  disease.  It  runs  a 
much  slower  course  than  the  epidemic  malady  generally  does,  and 
its  spinal  symptoms  are  less  marked.  In  some  instances  no  retrac- 
tion of  the  head,  or  stiffness  of  the  spine,  or  pain  in  the  extrem- 
ities, and  but  slight  impairment  of  the  special  senses,  have  been 
noticed.  Perhaps  the  singular  variations  in  temperature  will  be 
found  to  be  absent  in  the  sporadic  malady. 

There  are  other  diseases  with  which  cerebro-spinal  meningitis 
has  been  confounded  ;  for  instance,  owing  to  the  eruption  and 
to  the  sore  throat  which  may  attend  it,  with  scarlatina.  But  the 
onset  and  the  neck-symptoms  are  very  different ;  and  so  is  the 
eruption ;  certainly  it  is  different  in  its  course.     Still,  as  regards 


852  MEDICAL,   DIAGNOSIS. 

the  onset,  mc  must  bear  in  mind  that  both  may  be  ushered  in 
b}^  convulsions.  An  extremely  rapid  pulse  would  be  in  favor  of 
scarlatiua.  Cerebro-spinal  fever  also  resembles  at  times  the  onset 
of  maVK/nant  measles;  but  the  catarrhal  symptoms  and  presently 
the  eruption  guide  us. 

I  have  known  more  than  once  the  disease,  on  account  of  the 
congestion  of  the  lungs  or  the  broncho-pneumonia  which  may 
accompany  it, — and  in  some  epidemics  the  lung-affection  is  very 
marked, — to  be  mistaken  for  pneumonia.  In  truth,  the  diagnosis 
is  sometimes  far  from  easy.  The  mental  symptoms,  the  intense 
headache,  the  variations  in  the  pulse,  the  hypcra?sthesia,  the 
vomiting,  the  stiffness  and  retraction  of  the  muscles  of  the  neck, 
the  eruption,  are  distinguishing  traits  of  value ;  but  when  these 
important  symptoms  are  ill  defined,  much  doubt  may  exist.  So 
there  may  if  epidemic  cerebro-spinal  meningitis  become  inter- 
current, as  it  sometimes  does  in  pneumonia  as  well  as  in  other 
acute  affections.  Supervention  of  the  severe  headache,  and  ap- 
pearance of  rigidity  of  the  neck,  of  great  restlessness,  of  hyper- 
sesthesia,  and  of  coma,  are  the  symptoms  of  most  importance. 

In  some  instances  of  cerebro-spinal  fever  there  is  great  pain, 
with  some  SAvelling  of  the  joints,  and  the  disorder  is  thought 
to  be  acute  rheumatism.  But  the  head-symptoms,  the  state  of  the 
muscles  of  the  neck,  and  the  dissimilar  course  of  the  malady  soon 
clear  up  the  diagnosis. 

The  poison  may  produce  so  light  a  case  that  the  stiffness  of 
the  neck  may  be  mistaken  for  rheumatism  of  the  cervical  muscles. 
There  is,  however,  even  in  these  instances,  an  unusual  amount 
of  headache,  and  in  a  case  in  which  I  was  consulted  it  became  a 
permanent  condition  for  several  years,  and  then  yielded. 

Urocmia  with  contracted  kidneys  may  give  us  most  of  the  same 
symptoms  as  cerebro-spinal  fever,  especially  headache,  vomiting, 
and  retraction  of  the  head ;  careful  examination  of  the  urine  alone 
will  oxplain  the  case. 

Lastly,  let  us  look  at  the  clinical  features  separating  cerebro- 
spinal fever  from  the  disease  it  is  most  like, — typhus ;  let  us  con- 
trast its  phenomena  with  those  of  this  affection,  which  in  many 
respects  it  so  closely  resembles.  Both  diseases  are  apt  to  prevail 
at  the  same  time ;  both  attack  all  classes  and  ages  ;  both  are  evi- 
dently attended  with  dissolution  of  the  blood, — but  this  alteration 


FEVERS.  853 

in  the  blood  occurs  much  more  rapidly  and  is  much  more  marked 
in  epidemic  cerebro-spinal  fever  than  in  ordinary  cases  of  typhus;* 
the  eruption  is  different  from  that  of  the  common  form  of  typhus  ; 
we  find  less  delirium  ;  a  less  intense,  though  more  irregular,  fever ; 
the  affection  is  generally  of  much  shorter  duration ;  the  counte- 
nance is  not  of  a  dusky  hue  and  stupid,  but  pale  or  of  a  sallow 
color,  and  dull  or  expressive  of  suffering ;  and  there  is  the  stiff- 
ness of  the  muscles  of  the  neck,  with  the  fixed  spinal  pain,  and 
muscular  contractions  and  other  signs  of  spinal  or  cerebro-spinal 
lesion ;  and  the  herpetic  eruption  on  the  face.  Certainly,  there- 
fore, the  clinical  manifestations  of  cerebro-spinal  fever  are  very 
dissimilar  to  those  of  the  usual  varieties  of  typhus.  But  they 
are  not  so  dissimilar  to  those  occurring  in  some  epidemics  of 
malignant  cerebral  typhus. f 

Cerebro-spinal  fever  may,  during  an  epidemic,  complicate  other 
acute  maladies,  and  mix  its  symptoms  curiously  with  them.  With 
the  attack  the  difficulty  does  not  pass  off,  for  it  may  leave  all 
kinds  of  want  of  power  and  local  palsies,  besides  derangement  of 
vision,  permanent  deafness,  impaired  intelligence,  epilepsy,  per- 
sistent headache,  chronic  meningitis,  which  may  be  indeed  the  cause 
of  the  headache,  and  chronic  hydrocephalus.  In  one  instance 
I  have  known  an  extraordinary  swelling  of  the  whole  body  to 
follow ;  the  skin  is  hard,  tense,  and  greatly  thickened,  pits  very 
little  on  pressure,  except  around  the  ankles,  and  is  tightly  drawn 
over  the  face ;  this  swelling  and  thickening,  very  much  like  a 
general  sclerema,  has  now  lasted  for  upward  of  twenty  years,  and 
has  been  attended  with  a  feeling  of  numbness  in  the  skin  and  a 
moderate  amount  of  anaemia.  There  is  no  palsy  or  albuminuria ; 
the  patient  suffers  little  inconvenience,  except  from  her  size.  She 
has  a  waxy  countenance,  and  looks  like  a  very  fat  woman. 

*  The  deterioration  of  the  blood  occurs,  indeed,  very  soon  in  cerebro-spinal 
fever.  In  an  autopsy  of  a  child  that  died  in  twenty-four  hours,  I  found  the 
blood  diffluent  and  black  ;  in  an  adult  patient  who  had  been  ill  but  two  days, 
•  I  detected  blowing  sounds  in  the  heart,  evidently  of  blood-origin.  The 
poisoned  blood  unquestionably  gives  rise  to  many  of  the  nervous  symptoms, 
and  it  is  on  the  blood  and  the  nervous  centres  that  the  poison  mainly  acts. 

f  An  extraordinary  case,  bearing  on  the  relationship  of  the  complaints 
under  discussion,  was  under  my  charge  in  1865  at  the  Pennsylvania  Hospital. 
See  Case  XII.  of  a  series  of  typhus  fever  cases  published  in  Amer.  Journ. 
Med.  Sci.,  Jan.  1886. 


854  iMEDICAT.    DIAGNOSIS. 

Relapsing  Fever. — This  is  a  form  of  fever  cliaraoterized  bv 
its  rai)iJ  course  and  its  proneness  to  relapse.  Epidemics  of  this 
disease-^^ — and  it  occurs  only  in  epidemics — are  frequently  encoun- 
tered in  Ireland  and  in  Scotland.  In  this  country  it  was  until 
of  late  years  almost  unknown. 

The  disorder  is  decidedly  acute.  Its  inva^sion  is  sudden,  and 
marked  by  rigors,  pain  in  the  back  and  limbs,  vertigo,  severe 
headache,  and  nausea  and  vomiting.  Fever  is  soon  developed, 
and  rises  high,  it  may  be  to  between  107°  and  109°,  There  are 
severe  muscular  juiins,  particularly  in  the  muscles  of  the  extremi- 
ties ;  the  pulse  is  very  rapid  ;  the  temporal  arteri(!s  throb ;  the 
tongue  is  covered  with  a  thick  white  fur.  The  bowels,  as  a 
rule,  are  constipated.  In  many  cases  there  is  engorgement  of  the 
liver,  with  yellowness  of  skin  ;  and  in  nearly  all  there  are  epi- 
gastric tenderness  and  marked  enlargement  of  the  spleen.  The 
matter  ejected  from  the  stomach  is  greenish,  or  sometimes  black 
and  like  coffee-grounds.  Minute  points  of  extravasated  blood 
are  not  uncommonly  seen  upon  the  integument.  The  urine  is 
scanty,  and  contains  usually  bile-pigment,  some  albumen,  and 
hyaline  casts.  On  the  fifth  or  the  seventh  day,  though  some- 
times not  until  the  tenth,  the  symptoms  subside  as  speedily  as  they 
set  in,  a  profuse  perspiration  preceding  their  decided  abatement, 
and  the  temperature  falls  to  the  norm  or  even  below.  Convales- 
cence is  now  apt  to  be  rapid,  and  seemingly  complete,  the  patient 
being  up  and  going  about ;  but  the  apparent  return  to  health  does 
not  last  long.  Ordinarily  after  a  week,  therefore  on  the  twelfth 
or  fourteenth  day  from  the  first  beginning, — sometimes  sooner, 
rarely  later, — the  attack,  preceded  perhaps  by  a  slight  rise  in  tem- 
perature for  an  evening  or  two,  returns,  presenting  again  the  same 
signs,  and  again  terminating  by  a  critical  sweat  in  convalescence. 
This  second  attack  may  be  short  and  mild ;  but  it  may  be  both 
longer  and  of  graver  character  than  the  first.  It  is,  at  times,  fol- 
lowed by  another,  and  yet  another,  relapse.  When  the  patient 
finally  throws  off  the  disease,  he  is  very  weak,  and  his  blood  is 
much  impoverished.  He  shows  a  tendency  to  dropsy  of  the  ex- 
tremities; and  blowing  murmurs,  evidently  not  organic,  are  per- 
ceptible while  listening  to  the  heart.  These  murmurs,  however, 
may  also  be  heard  during  the  paroxysms.  The  patient  is  not 
really  well  during  the  intermission  ;  his  spleen  remains  enlarged, 


FEVERS.  855 

the  pulse  is  slow,  the  action  of  the  heart  is  weak,  and  the  muscu- 
lar and  arthritic  jmins  do  not  entirely  disappear. 

Relapsing  fever  has  an  intimate  connection  with  destitution. 
It  is  a  contagious  but  far  from  a  fatal  disorder,  except,  perhaps, 
in  the  negro.  In  fatal  cases  death  sometimes  happens  during  the 
first  paroxysm  as  the  result  of  syncope,  of  hemorrhage  into  the 
brain  or  from  the  lungs;  or  it  may  occur  suddenly  during  the 
intermission  from  paralysis  of  the  heart.  But  the  most  common 
termination  of  the  cases  having  an  unfavorable  issue  is  in  conse- 
quence of  complications  or  of  states  Avhich  have  been  induced  by 
the  malady,  such  as  lobular  or  lobar  inflammation  of  the  lung, 
hemorrhagic  pachymeningitis,  abscess  of  the  spleen  or  of  the  kid- 
ney leading  to  pysemia,  chronic  diarrhcea,  Bright's  disease,  dropsy, 
parotitis,  palsies.  At  times  the  patient  perishes  in  a  condition 
similar  to  the  collapse  of  cholera,  though  the  collajjse  is  more 
protracted  and  the  pulse  can  be  felt,  and  discharges  from  the 
bowels  are  by  no  means  a  constant  accompaniment.  The  ex- 
treme prostration,  attended  with  great  coldness  of  the  skin,  may 
last  for  days.  It  is  more  particularly  met  with  in  the  "  bilious" 
or  "  bilious  typhoid"  form  of  the  malady, — a  dangerous  variety, 
in  which  severe  vomiting,  jaundice,  and  delirium  are  encountered, 
and  the  paroxysm  is  not  followed  by  a  distinct  intermission  or 
remission,  but  often  by  the  signs  of  collapse  alluded  to,-  in  which 
ursemic  symptoms  have  been  more  particularly  noticed.*  The 
collapse,  however,  may  happen  not  only  at  the  close  of  the  par- 
oxysm, but  in  the  remission,  whether  this  be  distinct  or  not,  or  in 
a  subsequent  paroxysm  ;  and  this  may  be  the  case  no  matter  what 
variety  of  the  disorder  we  have  to  deal  with,  and  whether  or  not 
the  grave  symptoms  be  due  to  uraemia. 

Yet  the  state  of  the  kidneys  and  of  the  urinary  secretion  has 
commonly  a  great  deal  to  do  with  the  graver  phenomena  of  the 
malady.  Acute  renal  disease  with  albumen  and  tube-casts  in  the 
urine  was  discerned  by  Obermeierf  in  two-thirds  of  his  cases; 
and  as  regards  the  urine,  Reisenfeld  l  found  that  the  urea  during 
the  first  paroxysm  was  always  increased,  and  that  this  increase 
continued  beyond  the  crisis.      The  products  of  the  heightened 

*  Hermann,  Account  of  St.  Petersburg  Epidemic,  Schmidt's  Jahrb.,  No.  6, 
1865.     See  also  further  observations  in  Meissner's  article,  ib.,  No.  2,  1870. 
t  Virchow's  Archiv,  1869,  Bd.  xlvii.  t  Ib. 


856 


MEDICAL,   DIAGNOSIS. 


tissuc-mL'tamorphosis  may  be  retained,  aiul  thus  grave  symptoms 

arise. 

There  is  no  constant  obvious  lesion  in  relapsing  fever,  unless  it 

be  the  lesion  in  the  spleen.     This  organ  is  greatly  enlarged,  and 

presents  numerous  round  or  irregularly-shaped  bodies,  of  white 

or  yellowish-white   color.*      But 
Fig.  G3.  myriads  of  minute  organisms,  spi- 

rilla, are  found  in  the  blood  just 
prior  to  the  outbreak  of  the  par- 
oxysm, and  at  its  height.  Indeed, 
since  Obermeicr's  discovery  of  the 
spirilla  in  relapsing  fever,  there  is 
no  doubt  that  they  are  the  cause 
of  the  malady,  and  their  detection 
in  the  blood  removes  all  doubt  in 
the  diagnosis.  In  a  single  field 
of  the  microscope  we  may  see  but 
a  few  or  from  twenty  to  thirty 
spirilla. 

The  diagnosis  of  the  malady 
cannot  be  made  positively  during 
the    primary    seizure.      Yet    the 

Spirilla  of  relapsing  fever  (from  Heyden-    preseUCC    of    tllC     fcVCr,    whilc     an 
reich).     a,  single  spirillum  ;    b,    star-shaped     ^ 

bundle;  c,  nidus  of  spirilla,  with  biood-cor-  epidcmic    prcvails,    uiav  be    SUS- 

puscles.  ^  i  ^  - 

pected  from  the  sudden  fierce  be- 
ginning of  the  attack;  from  the  fact  of  the  high  fever-heat  of  104° 
to  107°  showing  itself  in  less  than  twenty-four  hours,  and  ex- 
hibiting either  a  morning  remission  of  one  to  two  degrees  and  the 
maximum  of  temperature  in  the  early  afternoon  or  evening,  or 
but  little  diiference  between  morning  and  evening,  until  the  rapid 
and  great  fall  which  takes  place  at  the  crisis ;  and  from  the  cliar- 
acter  of  the  gastric  symptoms.  Then  the  microscopical  examina- 
tion of  the  blood  is  of  great  importance.  Relapsing  fever  resembles 
ydloio  fever  in  its  short  duration  and  in  some  of  its  manifestations. 
But  there  is  this  evident  difference:  in  yellow  fever  the  paroxysm 
or  febrile  stage  is  usually  much  shorter ;  the  symptoms  in  the  re- 
mission do  not  subskle  nearly  so  completely ;  this  stage  is  a  very 


*  Pastau,  Yirchow's  Archiv,  1869,  Bd.  xlvii. 


FEVERS.  857 

brief  one  as  compared  with  the  decided  intermission  of  relapsing 
fever ;  the  black  vomit  of  yellow  fever  does  not  come  on  until 
the  stage  of  collapse  is  reached ;  and  this  far  more  fatal  malady 
presents  lesions  in  the  liver  and  heart  which  arc  not  found  in 
relapsing  fever,  while  it  does  not  show  the  extraordinary  enlarge- 
ment of  the  spleen. 

From  typhoid  and  typhus  fevers,  relapsing  fever  may  be  dis- 
tinguished by  the  shorter  prodromata,  by  the  presence  of  jaundice, 
by  the  absence  of  the  characteristic  eruptions,  and  by  the  short 
period  during  which  the  symptoms  last.  Again,  critical  sweats 
with  the  rapid  cessation  of  the  fever  are  not  likely  to  be  seen  in 
these  disorders,  certainly  not  in  typhoid  fever;  and  the  continuous 
very  high  temperature,  the  severe  muscular  and  arthritic  pains, 
the  tenderness  over  the  liver  and  the  spleen^  and  in  some  cases  the 
early  collapse  without  apparent  cause,  are  characteristic ;  while, 
on  the  other  hand,  delirium  and  stupor  are  rarely  encountered 
in  relapsing  fever.  After  the  relapse  has  taken  place,  the  diag- 
nosis is  easy,  if  the  case  have  been  watched  during  the  first 
attack.  But,  should  it  not  have  been  under  notice  before,  it  may 
be  at  times  very  difficult  to  say  whether  we  are  dealing  with  re- 
lapsing fever  or  with  a  relapse  of  typhoid  or  typhus  fever.  And 
this  difficulty  is  enhanced  by  the  want  of  uniformity  of  the  symp- 
toms in  the  second  onset  of  the  strangely  recurring  malady,  and 
the  close  similarity  they  occasionally  show  to  those  of  typhoid  or 
of  typhus  fever.  Another  difficulty,  too,  is  presented  by  the  fact 
that  relapsing  fever  may  exhaust  itself  in  the  first  paroxysm. 
But  this  is  a  very  unusual  occurrence,  and  the  abortive  cases  are 
generally  light.  In  them  too,  it  is  said,  the  spirilla  may  be 
detected  in  the  blood. 

Periodical  Fevers. 

These  fevers  are  characterized  by  the  distinct  periodicity  of 
their  phenomena:  they  exhibit  intervals  during  which  the  patient 
.  is  wholly  or  nearly  free  from  febrile  disturbance.  With  the  ex- 
ception of  one, — and  its  place  here  is,  indeed,  doubtful, — they  are 
all  owing  to  marsh  miasm,  or  malaria.  This  noxious  agent  gives 
rise  to  a  group  of  fevers  ever  betraying  their  common  origin 
by  their  strong  family  resemblance :  alike  in  occurring  in  low, 
swampy  localities;  alike  in  most  of  their  symptoms,  and  in  the 


858  MEDICAL   DIAGNOSIS. 

difficulty  of  eradication  from  the  system ;  alike  in  the  secondary 
lesions,  in  the  enlargement  of  tlie  si)leen  and  of  the  liver,  and 
in  the  altered  condition  of  tiie  blood,  which  they  leave  behind 
them  ;  and  also  alike  in  being  nnder  the  control,  absolnte  and 
immediate,  of  cinchona  in  its  varions  preparations.  Along  with 
the  forms  of  miasmatic  fever  I  shall  describe  yellow  fever;  not 
because  it  is  of  identical  nature,  but  on  account  of  the  similarity 
of  the  prominent  symptoms. 

Intermittent  Fever. — The  paroxysm  comes  on  with  a  chill : 
the  face  becomes  pale,  the  lips  bluish ;  the  teeth  chatter ;  the 
skin  is  cold  ;  there  is  a  feeling  of  uneasiness  and  fatigue.  After 
a  period  varying  commonly  from  half  an  hour  to  an  hour, 
this  cold  stage  passes  otf.  Now  we  find  decided  heat  of  the 
surface,  Avith  restlessness,  thirst,  a  full,  rapid  pulse,  muscular 
pains,  a  scanty  secretion  of  urine;  in  other  words,  active  febrile 
symptoms.  These  continue  for  hours,  for  a  period  always  much 
longer  than  the  first  stage  :  then  a  sweat  breaks  out  all  over 
the  body;  the  pulse  becomes  softer  and  less  frequent;  the  secre- 
tions are  fully  re-established ;  and  this  sweating  stage  terminates 
the  paroxysm. 

The  patient  is  now,  for  the  time  being,  well ;  but  the  disease 
soon  recurs  :  in  from  twenty-four  to  seventy  hours  the  paroxysm 
repeats  itself  In  the  former  case  we  call  the  fever  a  quotidian  ; 
in  the  latter,  a  quartan.  The  tertian  type  is  before  us  when  the 
paroxysm  sets  in  again  in  about  forty-eight  hours ;  the  double 
tertian,  when  we  find  a  daily  attack,  but  those  of  alternate  days 
alone  corresponding  in  time  and  severity.  Even  a  quintan  ague 
may  happen.*  The  period  between  the  ending  of  one  attack 
and  the  beginning  of  another  is  spoken  of  as  the  intermission, 
or  apyrcxia ;  while  the  time  between  the  beginning  of  the  two 
paroxysms,  including  the  first  with  its  succeeding  intermission,  is 
called  the  interval. 

The  varied  types  of  the  fever  present  marked  differences  in  the 
character  and  duration  of  the  several  stages.  The  tertian  has 
generally  the  longest  hot  stage,  the  quartan  the  longest  cold  stage. 
In  the  quotidian  there  is  a  short  cold  stage,  followed  by  a  hot 
stage  which  may  last  for  upward  of  fifteen  hours.     Occasionally 

*  Case  of  Henrv,  Brit.  Med.  Journ.,  Feb.  18, 


FEVERS.  859 

the  stages  are  very  irregular  and  anomalous.  Thus,  the  sweating 
stage  may  precede  the  cold  stage,  or  it  may  be  tlie  only  one  wliich 
shows  itself;  or,  again,  the  rigor  may  be  altogether  wanting. 
Sometimes  there  are  no  distinct  stages,  but  the  patient  has  a 
"dumb  ague,"  which  manifests  itself  at  definite  i^eriods  by  a  feel- 
ing of  great  depression,  or  of  a  severe  pain  at  some  portion  of 
the  body,  or  by  chilly  sensations,  or  by  headache,  or  by  nausea 
and  vomiting,  or,  as  I  have  seen,  by  excruciating  pain  over  the 
kidneys,  and  almost  entire  suppression  of  urine,  or  by  spasmodic 
obstruction  of  the  intestine.* 

Now,  cases  of  this  kind  are  difficult  to  distinguish  from  organic 
disease.  We  can  do  so  only  by  laying  stress  on  their  strictly  peri- 
odical nature ;  by  noting  that  the  curious  manifestations  cease 
entirely  to  recur  with  intensity.  This  does  not  happen  where  the 
symptoms  are  not  caused  by  a  lurking  malarial  poison  ;  for  idio- 
pathic disorders  exhibit  the  phenomena  of  structural  change  or  of 
deranged  function  at  all  times, — not  merely  on  certain  days  or  at 
certain  hours.  It  is  true  that  among  the  inhabitants  of  miasmatic 
districts  some  complaints,  and  particularly  those  of  the  nervous 
system,  display  a  well-defined  periodicity ;  but  here,  too,  are  found 
the  significant  traits  of  organic  or  functional  disturbance  between 
the  decided  exacerbations  of  the  symptoms. 

Then,  again,  we  must  remember  that  diseases  may  assume  an 
apparently  intermittent  character,  being  worse  every  second  day, 
and  yet  not  be  malarial  at  all.  Even  mania,  as  Schroeder  van 
der  Kolk  tells  us,  may  take  this  type.  The  whole  aspect  of  the 
symptoms,  and  a  tentative  treatment  with  quinine,  will  help  to 
inform  us  as  to  the  true  nature  of  the  malady. 

The  temperature  in  intermittent  fever  shows  a  peculiar  record, 
and  one  which,  in  doubtful  cases,  may  be  turned  to  great  advan- 
tage. Notwithstanding  the  marked  sense  of  chilliness,  the  ther- 
mometer rises  suddenly  and  rapidly  to  a  high  degree ;  there  may 
be  a  slight  elevation  of  temperature  for  an  hour  before  a  chill, 
but  the  striking  rise  begins  with  the  chill.  Even  during  the 
decided  chill  of  the  beginning  of  the  paroxysm  it  indicates  105° 
or  more  in  the  axilla.  The  temperature  remains  stationary,  or 
continues  to  rise,  though  not  much,  during  the  hot  stage,  and 

*  Cases  of  Hoyt,  Atlanta  Med.  and  Surg.  Journ.,  Sept.  1875. 


860 


MEDICAL    DIAGNOSIS. 


Fig.  64. 


during:  the  sweating  stage  lalls  at  first  slowly,  then  rapidly,  until 
it  comes  down  to  about  the  normal  heat.  During  the  chill  the 
peripheral  temperature  is  decidedly  lowered  ;  during  the  hot  stage 
it  is  increased.     But  with  tlie  ending  of  the  paroxysm  it  is  found 

that  the  fall  has  been  equally  rapid. 
In  the  intermission  the  thermometer 
in  the  axilla  marks  a  natural  temper- 
ature, or  one  somewhat  lower  than  in 
health.  It  rises  again  quickly  with 
each  paroxysm.  No  other  malady 
presents  these  variations. 

The  diagnosis  of  an  ordinary  and 
regular  intermittent  is  easy.  Leav- 
ing the  other  malarial  fevers  out  of 
consideration,  only  two  morbid  states 
are  likely  to  present  recurring  rigors 
and  febrile  excitement,  and  are,  there- 
fore, apt  to  be  confounded  with  it: 
hectic  fever,  and  chills  attending 
upon  suppuration  in  deep-seated 
parts.  Now,  hectic  fever  differs  in 
this  from  an  intermittent :  it  is  simply 
a  fever  of  irritation,  the  cause  of 
which  a  careful  scrutiny  will  gener- 
ally detect.  We  find  it  accompanying 
many  chronic  diseases  in  which  de- 
struction of  tissue  occurs,  especially 
phthisis ;  and  the  chronic  affection 
has  its  own  signs,  which  exist  at  all 
times,  whether  the  symptomatic  fever 
be  present  or  not.  Then  its  outbreaks 
are  irregular.  Several  often  take  place  within  the  twenty-four 
hours  ;  their  intermissions  are  incomplete ;  the  temperature  does  not 
fall  as  in  intermittent  fever,  for  there  is  not  complete  defervescence  ; 
and  although  the  paroxysms  may  begin  with  chilliness,  they  are 
not  ushered  in  by  a  well-defined  rigor.  Further,  they  are  apt  to 
be  morning  paroxysms,  and  are  not  modified  by  antiperiodics. 
Whenever,  indeed,  we  find  an  intermitting  fever  not  influenced 
by  these  agents,  it  ought  to  arouse  suspicion,  and  all  the  inter- 


Teniperutuie-rccord  of  a  tertiau  iuter- 
mittent. 


FEVERS.  8G1 

nal  organs,  particularly  the  lungs,  should  be  carefully  explored. 
Thus  only  can  serious  errors  in  diagnosis  be  guarded  against. 

When  jius  forms,  and  especially  when  it  forms  in  internal  cavi- 
ties, it  betrays  its  presence  by  rigors,  followed  by  more  or  less 
fever.  But  these,  unlike  the  chills  of  ague,  do  not  repeat  them- 
selves at  definite  periods.  Moreover,  in  the  midst  of  the  apparent 
intermission,  febrile  signs  or  other  manifestations  of  a  seriously 
disordered  system  may  be  discovered.  The  chills  of  ordinary 
pygemia  are  distinguished  by  the  same  phenomena;  then  the 
rigors,  unlike  the  malarial  malady,  are  often  characterized  by  the 
profuse  sweating  which  immediately  follows  them,  rather  than 
by  an  active  development  of  the  fever. 

But  there  are  other  causes  which  may  occasion  attacks  of  fever 
happening  in  paroxysms  and  simulating  ague.  They  may  occur 
in  disease  of  the  heart,  as  in  ulcerative  endocarditis  and  in  valvular 
aifections.* 

Gall-stones  which  form  in  the  radicles  of  the  hepatic  duct  in 
the  interior  of  the  liver  may,  as  Frerichs  shows,  give  rise  to  at- 
tacks of  chills  followed  by  heat  and  by  sweating,  easily  mistaken 
for  ague.  The  fact  that  these  febrile  phenomena  are  preceded 
in  many  instances  of  intra-hepatm  concretion  by  dull  pain  in  the 
hepatic  region,  and  by  sudden  sharp  seizures  of  pain  at  the  lower 
part  of  the  thorax  on  the  right  side,  is  very  significant.  Even 
gall-stones  passing  along  the  gall-duct  and  the  common  duct  may 
occasion  febrile  symptoms  like  those  of  an  intermittent,  with  pro- 
fuse hemorrhage,  if  they  have  led  to  inflammation  of  the  passage, 
and  the  paroxysms  may  extend  over  months,  and  then  the  patient 
recover.     Jaundice  is  apt  to  be  a  symptom  of  this  hepatic  fever. 

An  affection  which  on  account  of  the  chill  succeeded  by  fever 
miffht  be  mistaken  for  the  malarial  disorder  is  the  curious  so- 
called  urethral  fever  which  sometimes  arises  after  the  passage  of  a 
bougie,  and  which  may  even  terminate  in  death. f  Our  knowledge 
of  the  introduction  of  the  instrument,  and  the  non-recurrence  at  a 
fixed  time  of  the  rigor  and  febrile  phenomena,  furnish  the  points 
of  distinction. 

Yet  another  affection  liable  to  be  mistaken  for  intermittent  fever 


*  Ord,  St.  Thomas's  Hospital  Eeports,  1882. 

t  Eoser,  quoted  in  Brit,  and  For.  Med.-Chir.  Kev.,  Oct.  1867. 


8G2  MEDICAL   DIAGNOSIS. 

is  syphUHlc  fever.  The  fever  may  occur  in  attacks  consistiug  of  a 
chill,  followed  bv  a  hot  stage  and  sweating,  and  be  so  similar  to 
the  malarial  disorder  as  to  lead  to  error,*  The  apparent  ague-fits 
happen,  however,  toward  evening,  and  are  succeeded  or  accom- 
panied bv  severe  headache  and  pains  in  the  bones, — in  iact,  bv 
the  same  symptoms  as  the  more  ordinary  foi'm  of  syphilitic  fever. 
lu  the  form  in  which  the  febrile  symptoms  are  continuous,  these 
generally  precede  the  eruption  for  a  week  or  more,  and  may 
continue  after  this  appears. 

We  may  also  find  this  syphilitic  fever  with  symptoms  like 
those  of  malaria  in  cerebral  syphilis.f  This,  it  is  well  known, 
may  occur,  is  indeed  apt  to  occur,  years  after  the  early  manifes- 
tations of  syphilis,  though  the  brain  affection  may  happen  within 
six  months :  thus  the  paroxysmal  pyrexias  may  be  met  with  at 
very  varying  times  after  the  infection.  The  history  of  cerebral 
syphilis  must  often  be  considered,  to  luiderstand  their  meaning. 
AVe  must  bear  in  mind  that  disease  of  the  membranes  of  the 
brain  may  exist  which  may  disclose  itself  Math  great  suddenness 
or  gradually,  and  which  does  not  unusually  appear  with  apoplectic 
seizures ;  that  headache  is  a  very  marked  symptom  :  that  irregular 
motor  palsies  and  epileptic  attacks  frequently  happen,  as  well  as 
mental  failure  and  perversion,  and  symptoms  similar  to  general 
paralysis,  though  wanting  in  the  tremulousness.  The  aphasia 
which  may  be  met  Avith  is  said  to  be  very  commonly  associated 
with  left-sided  hemiplegia. 

In  tlie  puerperal  state  a  malarial  outbreak  may  happen  which, 
as  Morson  and  Fordyce  Barker  J  have  shown,  may  be  mistaken 
for  puerperal  fever.  Unlike  the  latter,  however,  the  puerpeval 
malarial  fever  is  attended  with  pain  in  the  head,  back,  and  limbs, 
and  does  not  generally  appear  so  soon  after  parturition, — not, 
therefore,  between  the  first  and  fifth  days  after  delivery.  ]More- 
over,  it  has  at  the  beginning  a  great  temperature-rise,  and  marked 
remissions  or  intermissions.  Puerperal  malarial  fever  may  lead, 
after  the  twelfth  day,  to  secondary  hemorrhage. 

*  See  cases  of  Bassereau,  referred  to  by  Bumstead  in  his  Treatise  on  Venereal 
Diseases;  Ord,  loc.  cit. 

t  Wood,  Transaetions  of  the  College  of  Physicians  of  Philadelphia,  Feb. 
1884 ;  alsa  in  Med.  News,  Philadelphia,  March,  1881 ;  Janow^ky,  quoted  ib. 

i  3Iedical  llecord,  Feb.  1880;   Virginia  Med.  Monthly,  Nov.  1881. 


FEVERS.  863 

Remittent  Fever. — This  is  a  fever  pre-eminently  of  hot 
cHmates  and  malarial  districts.  It  is  the  fever  of  Hungary, 
of  the  Pontine  Marshes,  and  particularly  of  Africa  and  the 
southern  portion  of  the  North  American  continent.  Occasion- 
ally, not  often,  we  meet  with  it  in  winter  and  in  early  spring ; 
very  generally,  during  the  summer  and  autumn  months. 

Remittent  fever  has  no  well-defined  and  constant  prodromic 
symptoms,  except,  perhaps,  a  singular  sense  of  gastric  uneasi- 
ness. It  is  ushered  in  by  a  marked  chill,  soon  succeeded  by 
violent  fever,  which,  after  a  varying  period,  decreases,  and  then 
breaks  out  again.  By  this  time  the  symptoms  of  the  disease  are 
very  apparent.  The  patient  complains  of  pain,  of  fulness  and  of 
throbbing  in  his  head.  He  is  restless  and  distressed ;  his  limbs 
ache ;  his  tongue  has  become  coated ;  he  suffers  from  thirst,  and 
rejects  the  contents  of  the  stomach.  After  continuing  at  their 
height  from  six  to  eighteen  hours,  these  symptoms  again  subside  : 
a  sweat  breaks  out  all  over  the  body ;  the  irritability  of  the  stom- 
ach lessens ;  the  patient  is  composed,  even  cheerful ;  his  headache 
has  nearly  ceased,  and  he  falls  into  a  quiet  slumber.  But  this 
lull  is  not  of  long  duration,  not  longer  than  some  hours.  Soon 
the  active  fever  is  rekindled :  the  skin  is  as  hot  and  dry  as  before, 
the  pulse  as  full,  frequent,  and  hard ;  the  spleen  is  observed  to  be 
swollen ;  and  the  other  symptoms  return  with  increased  intensity 
again  to  abate,  again  to  recur,  until  either  the  exacerbations  are 
effaced  and  the  fever  assumes  a  continued  type  and  then  gradu- 
ally lessens,  or  else  subsequently  the  remissions  become  better  and 
better  defined, — more,  indeed,  like  intermissions  than  remissions. 
In  the  progress  of  the  disease  at  and  after  its  height  the  pulse  is 
generally  quicker  and  weaker  than  at  first. 

The  temperature  rises  markedly  with  the  first  chill,  and  con- 
tinues to  rise  during  the  high  fever  that  follows.  With  the  sweat- 
ing stage  it  declines  by  several  degrees,  to  rise  to  a  greater  height 
than  previously  with  the  succeeding  febrile  phenomena ;  then 
again  there  is  a  fall  in  the  remission,  with  another  quick  rise  in 
the  fevei",  which  may  attain  a  very  high  point,  marking  from 
105°  to  108°.  The  greatest  height  is  usually  reached  in  the  ex- 
acerbation of  the  third  day.  After  this  the  remissions  become 
less  distinct,  and  may,  indeed,  be  recognizable  only  by  the  ther- 
mometer ;  the  whole  fever  is  more  like  a  continuous  one.     Sub- 


864 


MEDICAL   DIAGNOSIS. 


sequent  to  the  ninth  day  usually  the  remissions  are  very  marked, 
the  difference  between  the  heat  in  them  and  the  exacerbations 
being  three  degrees  or  more.  The  exacerbations  become  less  and 
less  high,  and  soon  cease,  the  temperature  falling  perhaps  pre- 
viously to  below  the  norm.  In  cases  in  which  the  fever  remains 
for  a  long  time  continuous,  irregular  remissions  occur,  especially 


Fig.  65. 


Pulse. 


Kesp. 


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Temperature  iu  a  case  of  remittent  fever  of  nio 
on  tlie  twelfth  day.    The  chart  shows  also 


derate  severity,  ending  in  recovery 
the  pulse  and  the  respiration. 


toward  the  end,  though  the  fever  may  preserve  its  continuous 
type  more  or  less  to  the  end. 

The  average  duration  of  the  fever,  unless  protracted  by  com- 
plications, is  from  nine  to  twelve  days.  Its  most  common  type 
is  quotidian,  or  rather,  perhaps,  double  tertian,  the  exacerba- 
tions of  alternate  days  corresponding  iu  severity,  in  duration,  and 
even  in  the  nature  of  the  symptoms.  Sometimes  there  are  two 
exacerbations  in  twenty-four  hours, — a  duplicated  quotidian, — or 
the  paroxysms  have  a  tertian  form.     The  exacerbations  may  occur 


FEVERS.  865 

any  time  in  the  twenty-four  hours ;  in  many  instances  morning 
exacerbation  is  noticed,  and  I  have  met  with  more  cases  in  which 
the  paroxysm  comes  on  in  the  afternoon  than  in  the  evening. 

The  urine  in  remittent  fever  presents  much  the  same  changes, 
though  iu  a  different  degree,  as  those  occurring  in  intermittent 
fever.  Its  color  is  deeper,  and  its  acidity  greater,  but  during 
convalescence  the  urine  passed  rapidly  becomes  alkaline,  throw- 
ing down  an  abundant  deposit  of  phosphates.  During  the  active 
stages  of  the  fever  there  is  an  increase  of  urea,  not  simply  above 
the  standard  of  health,  but  even  above  that  in  intermittent  fever ; 
and  this  increase  of  urea  is  attended  with  a  diminution  of  uric 
acid — unlike  what  happens  during  the  paroxysms  of  ague — and 
of  the  coloring  and  extractive  matter;  while,  as  convalescence 
sets  in,  the  urea  decreases  in  amount,  and  the  other  ingredients 
mentioned  increase.*  A  copious  deposit  of  urates,  forming  with 
the  phosphates  as  it  were  a  critical  discharge,  is  noticed  as  the  fever 
subsides,  and  is  analogous  to  what  takes  place  after  the  paroxysm 
in  intermittent  fever.  At  no  stage  does  the  urine  contain  albu- 
men, as  it  often  does  in  typhus,  and  generally  in  yellow  fever, 
but,  as  in  intermittent,  it  may  contain  sugar. 

Remittent  fever  is  readily  recognized :  the  rise  and  fall  of  its 
febrile  signs  are  too  striking  to  escape  observation.  Its  charac- 
teristic traits  are  more  closely  allied  to  those  of  intermittent  fever 
than  to  those  of  any  other  disorder.  But  there  are  these  points 
of  contrast :  in  intermittent  fever  each  paroxysm  begins  with  a 
chill,  which  is  not  the  case  in  remittent  fever ;  for  after  the  first 
paroxysm  there  is  rarely  a  marked  chill,  and  even  the  chill 
ushering  in  the  disease  is  usually  not  violent.  After  each  febrile 
exacerbation  comes  an  abatement, — not  an  intermission,  for  the 
thermometer  shows  that  the  fever  does  not  wholly  leave ;  the 
tongue  remains  coated,  and  the  gastric  derangement  does  not 
entirely  cease ;  the  patient  is  not  well,  as  after  a  fit  of  ague. 
The  symptoms  grow  and  decline ;  they  do  not  appear  and  dis- 
.  appear.  In  both  affections  we  may  have  herpes  labialis  at  the 
decline,  but  it  is  more  common  in  remittent  than  in  intermittent. 

Owing  to  the  jaundice  in  many  cases  of  bilious  remittent  fever, 

'  *  Joseph  Jones,  Observations  on  Malarial  Fever.  Extracted  from  the 
Transactions  of  the  American  Medical  Association. 

55 


866  MEDICAL   DIAGNOSIS. 

the  disease  is  often  mistaken  for  acute  congestion  of  the  liver. 
Here,  again,  the  exacerbations  and  remissions  in  the  temperatnre 
serve  as  distinguishing  marks;  and  so,  too,  in  separating  the 
gastric  complications  of  bilious  remittent  fever  from  acute  gastric 
inflammation.  The  severe  headache  is  also  a  distinctive  feature 
of  value  ;  so  is  the  herpes  labialis. 

Under  ordinary  circumstances,  there  is  very  little  likelihood  of 
confounding  with  each  other  typhoid  and  remittent  fevers.  The 
lines  between  the  two  diseases  are  too  strongly  drawn  :  no  marked 
periodicity  exists  in  typhoid  fever,  and,  on  the  other  hand,  we  find 
no  diarrhoea,  no  eruption,  no  thoracic  symptoms,  no  deafness,  and 
no  very  great  prostration,  in  remittent  fever.  But  instances  are  met 
with  in  which  the  diagnosis  is  not  easy,  because  the  symptoms  of 
the  two  maladies  are  blended.  Thus,  in  a  typhoid  fever  occurring 
in  a  malarious  region  there  are  often  distinct  exacerbations  and 
remissions  obscuring  the  real  ailment.  The  malarial  influence 
has  set  its  stamp  on  the  disease,  and  may  for  several  days  com- 
pletely veil  it ;  but  soon  its  real  nature  becomes  manifest.  The 
great  weakness ;  the  low  delirium ;  the  tympanitic  abdomen ;  the 
thin  passages,  so  unlike  the  dark,  hard  stools  of  remittent  fever, 
— all  unfold  the  true  character  of  the  disease.  Sometimes  a  cer- 
tain periodicity  is  witnessed  in  typhoid  fever  as  it  is  approaching 
a  favorable  termination ;  the  afternoon  or  evening  rise  of  temper- 
ature is  most  marked,  the  morning  remission  very  great.  Here  ii 
knowledge  of  the  previous  history  of  the  case  guards  against  error. 
We  shall  presently  again  refer  to  the  symptoms  of  periodicity  in 
fevers  of  low  type  in  examining  into  typho-malarial  fever. 

Further,  not  unfrequently,  after  an  attack  of  remittent  fever 
has  lasted  for  ten  or  twelve  days,  these  symptoms  are  noticed : 
great  muscular  debility,  jerking  of  the  tendons,  picking  at  the 
bedclothes,  dark,  dry  tongue,  and  weak  pulse,  perhaps  diarrhoea. 
The  fever  becomes  of  a  continued  type.  It  is  these  cases  which 
have  given  rise  to  the  opinion  that  bilious  fever  often  changes 
into  tjq^hoid  fever.  But  in  reality  it  is  not  so  much  the  specific 
typhoid  fever,  with  its  enteric  lesions,  as  a  typhoid  condition,  that 
is  developed. 

During  the  exacerbations  of  remittent  fever  the  cerebral  symp- 
toms are  sometimes  almost  identical  with  those  of  idiopathic  in- 
Jlammation  of  the  brain.     There  is  severe  headache,  with  violent 


FEVERS.  867 

beating  of  the  arteries  of  the  neck  and  face,  a  wild  eye,  intoler- 
ance of  light,  and  even  delirium.  Were  the  patient  now  seen  for 
the  first  time,  he  would  be  at  once  pronounced  to  be  laboring 
under  acute  meningitis.  Suddenly  the  pulse  loses  its  throbbing 
character,  a  perspiration  covers  the  surface,  and,  as  if  by  magic, 
the  cerebral  disturbance  ceases  until  the  next  paroxysm  rede- 
velops it.  Cases  of  this  kind  are  readily  enough  recognized,  if 
we  know  something  of  their  history.  If  we  are  not  familiar  with 
it,  we  have  to  await  the  remission  for  their  explanation ;  and  after 
the  sudden  withdrawal  of  the  signs  of  disorder  of  the  brain,  it  is 
hardly  possible  to  have  doubts  as  to  the  meaning  of  the  acute 
nervous  symptoms,  should  they  recur.  It  cannot  be  a  meningitis 
we  are  dealing  with, — a  steady,  progressing  disease,  and  one  never 
exhibiting  such  strange  freaks  of  intermission.  But  occasionally 
the  symptoms  show  themselves  under  circumstances  where  a  mala- 
rial poison  is  not  suspected  to  be  at  work : 

A  young  gentleman  of  studious  habits,  while  diligently  pre- 
paring for  a  college  examination,  was  seized  with  violent  headache 
and  fever.  The  sense  of  fulness  in  the  head  was  unbearable,  the 
fever  was  high,  there  was  nausea  with  great  gastric  irritability. 
These  symptoms  lasted  for  nearly  twenty-four  hours,  and  then 
subsided  in  the  forenoon,  to  become  aggravated  in  the  evening. 
Delirium  followed  by  great  drowsiness  was  perceived  at  an  early 
hour  of  the  third  day  of  the  disease.  The  case  now  assumed  a 
very  alarming  aspect.  Local  blood-letting  was  resorted  to  with 
some  relief,  and  in  a  few  hours  the  symptoms  were,  fortunately, 
favorably  modified  :  the  headache  was  much  less,  the  mind  was 
again  quite  clear.  Although  the  patient  had  never  suffered  from 
a  malarial  fever,  he  had  spent  part  of  his  summer  vacation  in  the 
marshy  neighborhood  of  Washington  ;  but  several  months  had 
elapsed,  and  winter  was  setting  in.  The  time  of  the  year,  there- 
fore, and  his  immediate  occupations,  rather  favored  the  view  of 
an  inflammation  of  the  brain.  But  the  evident  remission  in  the 
cerebral  symptoms,  the  coated  state  of  the  tongue,  and  that  in- 
describable malarial  look  of  the  countenance,  which  became  daily 
more  apparent,  decided  me  upon  administering  quinine.  The 
evening  exacerbation  came,  but  was  far  less  severe.  The  nature 
of  the  case  was  now  evident :  the  quinine  treatment  was  vigor- 
ously pursued,  and  the  patient  soon  recovered. 


868  MEDICAL    DIAGNOSIS. 

The  violent  headache  and  delirium  were  in  this  case  observed 
to  be  in  connection  with  well-defined  febrile  signs.  Occasionally 
one  or  both  of  the  symptoms  mentioned  last  during  the  remission, 
while  the  fever  abates.  I  have  even  met  with  them  occurring  in 
paroxysms  without  fever  being  present,  as  in  the  following  case 
seen  a  number  of  years  ago : 

A  voung  lady  of  delicate  constitution  was  attacked,  in  Septem- 
ber, with  remittent  fever.  The  disease  ran  its  course  without  any 
unusual  symptoms ;  a  violent  headache,  but  little  if  any  wander- 
ing of  the  mind,  being  observed  during  the  daily  exacerbations. 
After  the  tenth  day  the  fever  lessened,  and  the  disease  assumed  a 
continued  type ;  yet  soon  afterward,  as  convalescence  seemed  to 
be  established,  every  evening  for  three  days,  between  five  and 
six  o'clock,  a  boisterous  delirium  set  in,  lasting  for  three  or  four 
hours,  and  once  nearly  all  night.  It  was  followed  by  a  profound 
sleep,  from  which  she  woke  up  with  a  clear  mind.  During  these 
fits  the  pulse  was  not  accelerated,  and  there  was  no  heat  of  the  skin. 
The  third  attack  was  not  so  very  severe,  as  the  patient  was  already 
in  part  under  the  influence  of  decided  doses  of  quinine ;  the  fourth 
was  prevented  by  this  drug. 

In  both  these  cases  the  symptoms  approached  those  of  the 
congestive  type  of  the  disease,  and  the  issue  appeared  at  one  time 
doubtful.  Generally  speaking,  remittent  fever,  unless  it  be  of  the 
congestive  variety,  has  a  favorable  prognosis.  It  is  difficult  for 
us,  living  in  a  century  in  which  the  remarkable  effects  of  bark 
are  so  well  understood,  to  believe  that  the  complaint  was  once  so 
fatal,  and  that  so  many  deaths  should  have  taken  place  from  a 
disorder  over  -which  we  now  exercise  so  undoubted  a  control.  But 
the  long  list  of  distinguished  names  that  have  fallen  victims  to 
it,  among  them  Cromwell,  James  I.,  and  the  Emperor  Charles 
V.,*  proves  the  medical  skill  of  former  times  to  have  been  in- 
sufficient for  its  cure.  In  our  day,  the  consequences  of  remittent 
fever  are  more  to  be  dreaded  than  the  disease  itself.  We  often 
find,  as  its  sequelae,  obstinate  intermittents,  enlargement  of  the 


*  From  tlie  record  of  the  Emperor's  illness,  as  given  by  the  historian 
Mignet  (Charles  V  au  Monastere  de  Yuste),  we  may  learn,  what  fortunately 
now  we  hardly  have  an  opportunity  of  observing,  the  features  of  remittent 
fever  when  left  to  itself. 


FEVERS.  860 

liver  and  spleen,  dropsy,  protracted  ausernia,  headache,  and  im- 
paired activity  of  mind. 

It  is  in  this  malarial  cachexia  that,  on  pricking  the  finger 
and  examining  a  drop  of  the  blood  thus  obtained,  we  detect  a 
large  number  of  those  particles  and  masses  of  black  or  dark 
color  and  irregular  shape  to  which  Frerichs  has  particularly 
called  attention.  Not  that  the  pigment-matter  is  found  merely  in 
the  cachexia  following  remittent  fever.  We  observe  it  in  the 
blood  in  the  severer  forms  of  any  malarial  disease;  and  it  is 
very  probable  that  the  spleen  is  the  principal  seat  of  its  forma- 
tion, and  that  it  is  chiefly  derived  from  a  destruction  of  the  red 

Fig.  66. 


A  drop  of  blood  taken  from  the  finger  of  a  man  the  subject  of  malarial 
cachexia.  The  granules  of  pigment,  as  well  as  the  larger  fragments  of 
irregular  form,  are  seen  among  the  blood-globules.  The  pigment  vas 
for  the  most  part  black  ;   some  of  the  particles  were  reddish  bi  own. 

globules.  The  pigment  is  in  great  part  carried  from  the  spleen 
to  the  liver,  where  it  remains  ;  or  it  passes  through  this  viscus  to 
the  lungs,  brain,  and  kidneys.  The  clogging  of  the  coarser  frag- 
ments in  the  capillaries  of  the  liver  may,  as  Frerichs  suggests, 
by  interference  with  the  portal  circulation,  explain  the  intestinal 
hemorrhage  and  diarrhoea  which  attend  some  severe  cases  of 
remittent  fever;  while  the  cerebral  phenomena,  or  albuminuria, 
hsematuria,  or  suppression  of  urine  may  also  be  caused  by  reten- 
tion of  pigment,  in  the  one  case  in  the  capillaries  of  the  brain,  in 
the  other  in  those  of  the  Malpighian  bodies.  Thus,  then,  would 
be  solved  some  of  the  anomalous  symptoms  of  malarial  fevers. 


870  MEDICAL   DIAGNOSIS. 

But  the  abuiKlance  of  pig-mont  does  not  occur  in  all ;  and  whether 
a  peculiar  quality  or  an  unusual  intensity  of  the  miasm  produces 
it,  is  undetermined.  In  a  diagnostic  point  of  view,  though  from 
the  very  evident  grayish  or  ash-colored  hue  of  the  skin,  and  the 
singular  character  of  the  symptoms,  we  may  suspect  that  we  have 
to  deal  with  the  pathological  state  under  discussion,  we  cannot  be 
sure  of  it  until  we  have  examined  the  blood  microscopically.  And 
here,  too,  it  seems  to  me  that  the  question  of  the  amount  of  pig- 
mentary matter  present  must  not  be  overlooked.  For  pigment 
may  be  found  in  the  blood  of  those  who  never,  to  their  knowl- 
edge, have  had  intermittent  fever,  and  who  certainly  present  no 
signs  of  malarial  poisoning.* 

Parasitic  formations  have  been  described  by  Laveran  f  as  pres- 
ent in  the  blood  of  those  suifering  from  malarial  fevers ;  and  these 
minute  appearances  of  the  blood,  as  regards  both  the  micrococci 
and  the  masses  of  protoplasm  which  are  found  in  the  red  corpus- 
cles of  the  blood,  are  of  distinct  diagnostic  value.  In  the  latter 
is  reddish  or  black  pigment,  due  to  the  action  on  the  haemoglobin. 
The  hsematozoa  of  malaria  in  their  varied  forms  are  represented 
in  the  drawings  on  the  opposite  page,  made  from  cases  mainly 
under  my  care  at  the  Pennsylvania  Hospital,  and  drawn  by  Dr. 
Joseph  Leidy,  Jr.  Bodies  1,  2,  and  3  were  found  iu  the  blood 
of  a  case  of  malarial  paralysis.J 

To  the  peculiar  appearance  of  the  tongue  which  those  under 
the  malarial  influence  may  show,  Osborn  has  directed  particular 
attention. §  There  is  a  distinct  lateral  boundary  of  the  organ,  an 
appearance  of  indentation  transversely,  and  the  inferior  surface 
appears  to  have  encroached  upon  the  superior  and  lateral  borders. 

Since  the  discovery  by  Bence  Jones  of  the  existence  in  animal 
textures  of  a  substance  resembling  quinine,  the  diminution  of 
this  "  animal  quinoidine"  has  been  thought  to  occur  in  malarial 

*  J.  F.  Meigs,  Pennsylvania  Hospital  Keports,  vol.  i.,  1868. 

t  Bulletin  de  la  Societe  Medicalc  de  Paris,  1880. 

J  Dr.  Leid}''  has  called  my  attention  to  the  effect  of  heat  and  of  cold  on  ordi- 
nary blood-corpuscles :  they  are  distorted,  and  changes  are  produced  which 
might  easily  be  taken  for  some  of  the  forms  of  the  hasmatozoa  of  malaria.  It 
is  also  very  important  to  cleanse  the  part  thoroughly'  from  which  the  blood  is 
taken,  as  epithelial  cells  filled  with  pigment  or  free  pigment  from  the  skin  might 
otherwise  be  mistaken  for  malarial  changes  in  the  blood. 

§  Transactions  of  the  American  Medical  Association,  vol.  xx. 


FEVERS. 


871 


disease.  But  it  is  now  known  that  the  fluorescent  substance  is  in- 
troduced in  the  food  taken,  and  is  rapidly  excreted.*  The  more 
rigid  diet  of  fever  jaatients  explains  the  apparently  abnormal 
decrease  of  the  animal  quinoidine. 


Pig.  67. 


a,  a',  vacuoles  containing  pigment;    6,  pig- 
mented body,  outside  of  corpuscle. 


a,  a',  hyaline  bodies. 
4. 


^ 


o,  o,  pigmented  bodies, — the  haemoglobin  is 
entirely  consumed  in  one  corpuscle;  6,  hy- 
aline body. 


a,  cresceutic  body  ;  b,  h,  pigmented  vacuoles. 


«,  a,  a,  amoeboid  bodies ;  h,  pigmented  vacuole. 


a,  pigmented  ciliated  body,  flagellated  or- 
ganism of  Laveran  ;  h,  mass  of  free  pigment. 
(Ii"rom  a  case  of  pernicious  malaria.) 


In  children,  a  fever  of  remittent  type  is  observed,  called  infan- 
tile remittent,  which  is  rarely  a  miasmatic  disorder.  It  is  often  a 
gastro-enteritis  connected  with  verminous  irritation  or  produced 
by  errors  in  diet ;  or  a  typhoid  fever, — an  aifection  M'hich  now 


*  Chalvet,  Gazette  Hebdomadaire,  v.,  1868. 


872  MEDICAL   DIAGNOSIS. 

and  then  occurs  even  in  very  young  cliildren.  "What  has  given 
rise  to  this  confusion  is,  that  all  febrile  diseases  in  children  ex- 
hibit a  much  greater  periodicity  tlian  in  adults,  and  in  all  cerebral 
symptoms  are  apt  to  be  present.  To  distinguish  the  two  maladies 
mentioned  from  true  remittent  fever,  we  must  study  particularly 
their  manner  of  beginning  and  their  probable  origin,  and  note  the 
peculiarities  of  the  abdominal  symptoms.  Then  we  may  lay  stress 
on  the  irregular  mode  and  the  unequal  duration  of  the  febrile  ex- 
acerbations. Sometimes,  also,  by  close  scrutiny,  the  characteristic 
eruption  of  a  low  continued  fever  may  be  found  in  an  apparent 
remittent. 

But  some  of  these  cases  of  remittent  fever  are  really  of  malarial 
origin  ;  even  in  very  young  children  this  may  be  their  source.  I 
saw,  for  instance,  some  years  ago,  a  little  girl,  three  years  of  age, 
who  had  a  distinctly  malarial  remittent  fever,  which  was  checked 
by  antiperiodics.  During  the  violent  exacerbations  she  was  veiy 
delirious ;  her  face  had  a  most  anxious,  frightened  look ;  her 
screams  could  be  heard  all  over  the  house.  In  the  remissions 
she  was  perfectly  sensible,  but  there  was  gastric  irritability,  and 
the  bowels  were  very  constiiDated.  I  have  met  with  a  similar  case 
in  an  infant  of  eighteen  months. 

Congestive  Fever. — This  is  a  malignant,  destructive,  ma- 
larial fever,  which  may  be  either  of  the  intermittent  or  of  the 
remittent  form.  The  pernicious  attacks  are  of  the  tertian  or  of 
the  quotidian  tyiDe.  While  they  are  at  their  height,  there  is  in- 
tense congestion  of  one  or  several  internal  organs,  with  a  dangerous 
perversion  of  the  function  of  innervation.  From  this  state  the 
patient  may  rally,  but  only  to  fall  a  victim  to  another  paroxysm 
unless  art  intervene.  The  temperature  during  the  chill  and  sub- 
sequent fever  ranges  from  104°  to  108°.  Sugar  is  apt  to  be 
found  in  the  urine  much  more  commonly  than  in  ordinary  inter- 
mittent fever. 

The  symptoms  of  this  violent  malady  vary  according  to  the 
organ  more  specially  disturbed,  and  to  the  extent  of  the  derange- 
ment of  the  nervous  system.  We  have,  thus,  several  distinct 
varieties,  of  which  I  shall  describe  the  most  prominent. 

The  gastro-enteric  form  is  common  in  our  Southwestern  States. 
Its  distinctive  features  are  nausea  and  vomiting,  purging  of  thin 
discharges  mixed  with  blood,  intense  thirst,  and  an  equally  intense 


FEVERS.  .  873 

desire  for  air.  There  is  little  abdominal  pain  or  tenderness,  but 
a  weak,  frequent  pulse,  and  very  great  restlessness.  The  patient 
complains  of  a  sense  of  sinking  and  of  weight,  and  of  burning 
heat  in  the  stomach.  His  breathing  is  deep-drawn;  to  each 
expiration  succeed  two  short  inspirations.  The  face,  hands,  and 
feet  are  pale  and  cold  ;  the  features  shrunken.  Sometimes  these 
symptoms  continue  for  several  days,  and  gradually  increase  in 
intensity,  in  spite  of  nature  making  efforts  at  reaction.  More 
frequently  reaction  does  take  place ;  the  temperature  is  very  high, 
the  pulse  feeble,  and  the  stormy  symptoms  subside  or  wholly 
yield,  until  another  outbreak,  which  is  very  apt  to  be  deadly, 
occurs.  The  usual  length  of  the  fatal  paroxysm  is  stated  by 
Parry,*  in  his  short  but  interesting  sketch  of  the  disease,  to  be 
from  three  to  six  hours. 

The  thoracic  variety  of  the  malady  is  often  combined  with  the 
one  just  described.  Its  most  characteristic  trait  is  violent  dyspnoea, 
caused  by  overwhelming  congestion  of  the  lungs.  It  is  perhaps 
the  most  rapidly  destructive  of  all  the  forms  of  the  disastrous 
affection. 

In  the  cerebral  variety  there  is  intense  congestion  of  the  brain  ; 
and  sometimes  effusion  of  serum  into  the  ventricles  takes  place, 
or  even  rupture  of  the  blood-vessels.  The  abnormal  state  of  the 
brain  manifests  itself  either  by  coma  or  by  delirium.  In  the 
former  case  there  is  usually  preceding  stupor  with  occasional 
delirium  ;  the  pulse  is  slow  and  full ;  the  face  is  dull,  and  either 
flushed  or  livid ;  indeed,  some  of  the  symptoms  which  are  ob- 
served in  apoplexy  show  themselves.  When,  on  the  other  hand, 
delirium  is  marked,  we  have  much  the  same  morbid  phenomena 
as  in  acute  meningitis :  the  patient  is  wild ;  he  sings,  he  cries. 
He  may  die  in  this  state  without  coma  supervening;  but  a  coma- 
tose condition  generally  succeeds  rapidly  to  the  fierce  excitement. 
Should  recovery  take  place,  the  delirium  gradually  ceases. 

Another  variety  much  dwelt  upon  is  the  so-called  algid  form. 
This  is  not  often  seen  in  this  country ;  Maillot  f  noticed  it  in  Cor- 
sica and  Algeria.  The  disease  is  more  than  a  mere  continuation 
of  the  cold  stage  of  a  paroxysm :    commonly  the  characteristic 

*  Amer.  Journ.  Med.  Sci.,  July,  1843. 

f  Traite  des  Fievres  intermittentes,  Paris,  1836. 


8/4  MEDICAL   DIAGNOSIS. 

symptoms  manifest  themselves  during  the  period  of  reaction. 
The  pulse  slackens,  and  finally  ceases ;  the  extremities,  face,  and 
trunk  become  in  succession  rapidly  cold.  There  is  no  thirst ;  the 
skin  feels  like  marble ;  the  breath  is  cold  ;  the  voice  broken. 
The  mind  is  clear ;  the  expression  of  the  countenance  impassive 
and  like  that  of  a  dead  man.  There  may  be  vomiting  and  chole- 
raic discharges.  These  symptoms  go  on  steadily  toward  death, 
unless  decided  reaction  be  brought  about. 

In  none  of  these  forms  of  congestive  fever  is  the  first  paroxysm 
apt  to  be  of  a  pernicious  character.  In  the  majority  of  instances 
the  disease  begins  as  oixlinary  periodic  fever,  and  it  is  only  in  the 
second  or  third  paroxysm  that  the  alarming  symptoms  appear. 
Nor  is  the  first  congestive  paroxysm  likely  to  prove  mortal ;  gen- 
erally it  is  not  until  the  second  or  third  that  a  fatal  issue  is  to  be 
apprehended.  Proper  watchfulness  will  sometimes  detect,  even 
at  the  onset  of  the  attack,  by  the  unusual  prolongation  of  the 
cold  stage,  or  by  the  irregularity  of  the  pulse,  or  by  the  great 
sensitiveness  in  the  splenic  region  and  by  the  pain  which  press- 
ure there  may  occasion  all  over  the  body,  or  by  an  imperfect  hot 
stage,  or  by  the  feeling  of  internal  heat  while  the  surface  is  really 
cold,  the  danger  that  is  approaching,  and  arrest  its  further  steps 
by  the  bold  use  of  antiperiodics.* 

The  cause  of  this  desperate  disease  is  evidently  a  highly  active 
malarial  poison ;  and  once  in  the  system,  it  remains  for  a  long 
time.  Should  the  patient  even  weather  the  first  attack  com- 
pletely, he  is  not  wholly  out  of  danger ;  he  may  have  a  second 
seizure  quite  as  dangerous  within  the  same  season. 

*  For  observations  illustrative  of  the  different  forms  of  the  disorder,  see 
Louis,  New  Orleans  Journal,  vol.  iv. ;  Ames,  ib. ;  Holmes,  American  Med- 
ical Intelligencer,  vol.  xxxix.  ;  Ford,  Southern  Medical  Journal,  vol.  iv.  ; 
also  Bartlett  on  the  Fevers  of  the  United  States ;  Diclcson,  Elements  of 
Medicine ;  Semenas,  De  la  Fievre  pernicieuse  chez  les  Enfants,  Paris,  1848 ; 
Henoch,  Berlin.  Klinische  Wochenschrift,  1873;  Sullivan,  Medical  Times 
and  Gazette,  March,  1876;  Cooke,  New  Oi'leans  Med.  and  Surg.  Journ.,  N.  S., 
X.,  1882;  Tourtoulis,  Paris,  1882;  Bemiss,  Medical  News,  Phila.,  1883,  xlii. ; 
C.  Bevill,  St.  Louis  Cour.  Med.,  1884,  xii.  ;  Louis  Loisel,  Du  Traitement  des 
Fievres  paludeennes  a  Sainte-Marie  de  Madagascar,  etc.,  Paris,  1885;  J.  Jones, 
Virginia  Med.  Month.,  1886-7,  xiii.  ;  Doussin,  Poitou  Med.,  Poitiers,  1886,  i., 
No.  2;  H.  Duchon-Doris,  La  France  Med.,  Paris,  1887,  i.  ;  E.  L.  Crutchfield, 
Virginia  Med.  Month.,  1887-8,  xiv. ;  A.  W.  Reyes.  Cron.  med.-quir.  de  la 
Haljana,  1888,  xiv.  ;  D.  S.  Gardner,  Med  Standard,  Chicago,  1889,  v. 


FEVEIIS.  875 

Hemorrhagic  llalarial  Fever. — Closely  connected  with  congest- 
ive fever,  indeed  in  a  certain  sense  a  form  of  it,  is  that  per- 
nicious malady  which  is  attracting  in  this  country  more  and  more 
attention,  and  is  known  as  the  yellow  disease,  icterodc  pernicious 
fever,  malarial  hsematuria,  or  hemorrhagic  malarial  lever.  It 
is  the  same  disease  as  that  which  some  of  the  French  writers 
have  long  described  as  hsematuric  bilious  fever,  and  is  found  in 
intensely  malarial  places,  sometimes  in  epidemics.  It  usually 
occurs  in  those  who  have  already  suffered  much  from  malarial 
fevers,  and  is  almost  always  ushered  in  by  a  marked  chill,  longer 
usually  and  more  intense  than  the  patient  has  had  in  the  pre- 
ceding seizure  of  intermittent, — for  often  the  dangerous  paroxysm 
is  preceded  by  one  of  ordinary  kind.  Soon  after  the  protracted 
chill,  distressing  nausea  and  vomiting  are  noticed,  as  well  as 
headache,  great  restlessness,  and  rapidly-developed  deep  jaundice. 
The  fever  which  follows  the  chill  is  not  high,  the  pulse  is  rarely 
extremely  rapid,  the  patient  is  very  thirsty.  In  a  few  hours  after 
the  chill,  pain  in  the  right  hypochondrium,  in  the  epigastrium, 
and  over  the  kidneys  is  encountered,  and  a  dark-colored,  bloody 
urine  is  voided.  Sometimes  hemorrhages  occur  also  from  the 
nose  and  bowels.  The  type  of  the  fever  is  either  intermittent  or 
remittent ;  occasionally  it  is  continuous.  The  bloody  urine — for 
I  know  the  dark-colored  urine,  judging  from  the  specimens  I  have 
examined,  to  be  bloody  or  to  contain  large  quantities  of  dissolved 
haemoglobin — is  at  times  associated  with  considerable  albumen 
and  with  tube-casts. 

If  the  case  progress  unfavorably,  the  pulse  rises,  cold  sweats 
occur,  purpuric  spots  appear  on  the  skin,  and  the  signs  of  uremic 
poisoning  are  not  unusual.  In  the  intermission  or  remission  the 
symptoms  abate  considerably,  jaundice  and  bloody  urine  cease  to 
a  great  extent,  perhaps  almost  entirely, — at  least  this  is  true  of 
the  latter  symptom, — but  they  recur  in  the  paroxysms,  which  may 
happen  every  day  or  every  ten  or  twelve  hours. 

The  disease  may  prove  fatal  in  three  days ;  but  generally  it  lasts 
longer.  Convalescence  is  apt  to  set  in  slowly,  and  not  until  the 
urine  has  entirely  and  permanently  cleared.  The  liver  and  spleen 
may  remain  for  a  time  greatly  enlarged. 

As  regards  the  diagnosis  of  the  disease,  there  are  but  two 
diseases  that  closely  resemble  it.    One  is  intermittent  heematinuria. 


876  MEDICAL   DIAGNOSIS. 

Now,  undoubtedly  some  of  the  recorded  cases  of  this  are  cases 
of  the  malady  under  discussion ;  but  in  those  to  which  the  name 
can  be.  fairly  given  the  absence  of  marked  malarial  elements,  of 
jaundice,  of  retl  blood  disks  in  the  urine,  and  the  want  generally 
of  fever,  supply  the  distinguishing  traits.  From  yellow  fever,  for 
which  hemorrhagic  malarial  fever  may  be  mistaken,  it  differs  in 
the  speedy  occurrence  of  marked  jaundice,  in  the  bloody  urine, 
in  the  extreme  rarity  of  black  vomit,  in  the  course  of  the  fever 
with  its  recurring  paroxysms,  and  in  the  high  degree  of  malarial 
poisoning  which  the  history  of  the  case  proves.* 

Then,  again,  the  malarial  poison  may  affect  the  kidneys,  pro- 
ducing altered  secretion  and  even  transitory  albuminuria,  and 
may  lead  to  recognizable  organic  change.f 

Before  proceeding  to  the  discussion  of  another  subject,  I  shall 
here  devote  a  few  pages  to  the  consideration  of  some  of  the  ir- 
regular forms  and  modifications  of  malarial  poisoning,  and  to  its 
share  in  producing  febrile  disorders  of  blurred  and  uncertain 
type.  Practically,  this  is  of  great  importance,  and  specially  of 
importance  to  American  physicians. 

In  the  first  place,  I  shall  speak  of  the  chronie  malarial  j)oison- 
ing  so  often  seen  among  inhabitants  of  malarial  districts.  It 
manifests  itself  by  lassitude,  debility,  torpor  of  the  liver,  and 
enlargement  of  the  spleen.  The  stools  are  often  black,  the  diges- 
tion is  impaired,  the  complexion  sallow.  Occasionally  attacks  of 
jaundice  occur,  which  rather  relieve  than  aggravate  the  unhealthy 

*  The  literature  of  the  subject  is  becoming  extensive.  Among  the  most 
valuable  publications  are  those  of  R.  F.  Michel,  New  Orleans  Journal  of 
Medicine,  July,  1869;  Osborn,  i&.,  Jan.  1869;  Norcom,  Address  before  the 
Medical  Society  of  North  Carolina ;  E.  D.  McDaniel,  Transact.  Med.  Assoc, 
of  Alabama ;  E.  D.  Webb,  Hemorrhagic  Malarial  Fever,  Livingston,  Ala. ; 
Berenger-Feraud,  Fievre  bilieuse  melanurique,  Paris,  1874;  Watkins,  New 
Orleans  Med.  and  Surg.  Journ.,  1881,  N.  S.,  vol.  viii.  ;  McDaniel,  Medical 
News,  Phila.,  1883,  xliii. 

t  See  papers  on  malarial  changes  in  the  kidnej-s  in  Arch,  de  Phys.,  1882, 
Nos.  1,  2,  3;  and  on  malarial  htematuria,  T.  F.  Wood,  North  Carolina  Med. 
Juurn.,  1884,  xiv.  ;  J.  Cochrane,  Journ.  Amer.  Med.  Assoc,  Chicago,  1885, 
iv. ;  I.  J.  Newton,  Jr.,  Transact.  Louisiana  Med.  Soc,  1885,  vii. ;  R.  H.  Day, 
Therap.  Gaz.,  1886,  3d  S.,  ii. ;  B.  H.  Riggs,  Alabama  Med.  and  Surg.  Journ., 
1886,  i. ;  W.  L.  Van  Horn,  Gaillard's  Med.  Journ.,  1887,  xliii.;  J.  W. 
McLaughlin,  New  Orleans  Med.  and  Surg.  Journ.,  1888-89,  N.  S.,  xvi.  ; 
I.  T.  Young,  South.  Med.  Rec,  1889,  xix. 


FEVERS.  877 

state  of  the  system.  Sometimes  the  noxious  influence  shows  itself 
in  another  way  :  the  patient  is  seized  with  nausea,  and  with  gastric 
irritabihty  so  great  that  ahiiost  everything  he  takes  is  instantly 
rejected.  The  tongue  is  coated,  the  skin  dryish  ;  Init  he  has  little 
if  any  fever.  The  bowels  are  confined,  the  urine  is  turbid.  He 
is  restless,  and  as  weak  as  if  he  had  typhoid  fever ;  but  he  has 
•neither  an  eruption  nor  diarrhoea.  His  sleep  is  disturbed,  and  he 
often  suffers  with  hypersesthesia  of  the  scalp,  and  neuralgic  pain 
shooting  over  the  forehead  and  causing  twitching  of  the  eyelids. 
After  remaining  from  six  to  seven  days  in  this  condition,  his 
nails,  perhaps  at  a  certain  hour  every  day,  are  noticed  to  become 
bluish  ;  or  he  feels  chilly,  and  a  slight  fever  immediately  after- 
ward sets  in.  The  return  of  these  febrile  symptoms  is  checked 
by  quinine,  and  the  patient  enters  upon  a  slow  convalescence, 
remaining  for  a  long  time  enfeebled.  Again,  there  may  be  head- 
ache, coming  on  at  a  certain  hour,  associated  with  rise  of  temper- 
ature. We  also  encounter  malarial  neuralgias  and  malarial  pal- 
sies. In  these,  as  in  a  case  under  my  care  at  the  Pennsylvania 
Hospital  in  1889,  the  detection  of  the  malarial  corpuscles  in  the 
blood  led  to  its  recognition. 

Typho-malcmal  Fever. — Fevers  of  hybrid  character,  for  the 
most  part  of  kindred  nature  to  those  low  states  of  malaria  just 
described,  have  long  been  recognized  by  practitioners  in  this 
country.  But  it  is  only  since  our  civil  war  that,  owing  to  the 
publications  of  Woodward,  they  have  been  set  apart  in  a  sep- 
arate class.  Now,  one  of  the  most  marked  forms  of  '"typho- 
malarial  fever,"  to  adopt  this,  from  a  practical  point  of  view, 
convenient  name,  was  that  curious  fever  which  so  many  soldiers 
brought  wdth  them  from  the  swamps  of  the  Chickahominy. 
Without  attempting  to  describe  it  in  full,  I  shall  give  a  sketch 
of  the  phenomena  I  noticed  among  those  who  had  been  with  the 
army  during  the  Peninsular  campaign  and  were  sent  to  Philadel- 
phia for  medical  treatment. 

The  fever  generally  began  with  a  decided  chill,  to  which  febrile 
excitement  soon  succeeded.  This  chill  was  sometimes,  but  not 
always,  repeated.  Many  cases  of  the  disorder  showed  at  first 
distinct  remissions;  but  if  the  fever  lasted  for  more  than  a  week 
it  became  continued.  Diarrhoea  was  a  prominent  symptom  from 
the  first;    sometimes  it  preceded  the  disease  by  several  weeks. 


878  MEDICAL    DIAGNOSIS. 

In  the  cases  that  I  saw  in  Philadolj^hia,  nausea,  vomiting;  of  bile, 
and  great  thirst  were  often  present ;  the  stools  were  very  freqncnt 
and  offensive  ;  the  eye  was  injected.  There  was  generally  mental 
confnsion,  and  not  nnnsnally  wild  delirinm ;  but  no  eruption, 
— certainly  no  rose-colored  spots.  The  tongue  was  sometimes 
coated,  but  often  smooth,  clean,  and  moist.  The  debility,  after 
the  affection  had  reached  the  middle  or  the  end  of  the  second 
week,  was  extreme.  The  face  was  pale,  dull  in  its  expression, 
and  became  from  day  to  day,  like  the  rest  of  the  body,  more  and 
more  emaciated.  It  was  mostly  of  a  very  sallow  hue,  seldom 
really  jaundiced  ;  at  least  the  conjunctivae,  although  injected,  were 
not  discolored.  The  skin  was  dry,  and  not  very  hot.  The  heart- 
sounds  were  feeble,  as  was  also  the  pulse.  The  lungs  generally 
remained  healthy.  In  the  third  week  of  the  disease  the  patient 
was  apt  to  enter  upon  convalescence,  or  he  died  utterly  exhausted, 
free  stimulation  exerting  but  little  effect. 

The  post-mortem  examinations  were  only  to  a  certain  extent 
satisfactory,  as  regards  the  light  they  thrcAv  upon  the  symptoms. 
In  a  large  number  of  instances,  perhaps  in  the  majority,  neither 
the  solitary  nor  Peyer's  glands  were  ulcerated.  They  were  fre- 
quently, however,  found  to  be  swollen,  sometimes  of  very  dark 
color,  and  the  seat  of  pigment  deposit.  The  mucous  membrane 
of  the  lower  portion  of  the  ileum  and  of  the  colon  was  often  seen 
to  be  congested,  even  inflamed.  The  heart  was  several  times 
noted  as  flabby.  None  of  the  other  organs  presented  any  constant 
lesions,  except  that  the  spleen  was  always  much  enlarged. 

The  convalescence  from  the  fever  was  slow ;  and  during  this 
protracted  recovery  symptoms  occurred  quite  as  striking  as  those 
of  the  fever  proper.  Those  who  got  well  did  so  with  a  broken 
constitution,  and  showed  for  months,  by  their  wan  faces  and  their 
great  debility,  the  hold  the  disease  had  had  upon  them.  Some- 
times, after  gaining  strength  slowly  for  a  time,  they  lost  ground 
again,  and  relapsed  into  a  typhoid  condition  very  similar  to  that 
of  the  first  attack,  except  in  exhibiting  an  almost  undisturbed  state 
of  the  mind  and  a  more  continued  character  of  the  fever. 

The  blood  was  left  much  impoverished.  This  fact  manifested 
itself  by  the  pallid  face,  the  blood-murmurs  heard  over  the  heart, 
the  irritability  of  that  organ,  and  the  dark-purple  spots,  un- 
changed by  pressure,  Avhich  showed  themselves  at  times  all  over 


FEVERS.  879 

the  body,  and  often  did  not  appear  until  long  after  the  fevei'  had 
left. 

As  other  seqnelse  of  the  fever,  for  in  a  certain  sense  they  were 
seqnelte,  I  noticed  milk-leg,  enlargement  of  tlie  liver,  tympanites, 
parotitis,  irritable  heart,  and  diarrhoea,  which  ceased  at  times,  but 
only  to  break  out  again.  The  looseness  of  the  bowels  was  not 
generally  associated  with  ulceration  or  thickening  of  the  intes- 
tinal mucous  membrane ;  the  solitary  and  agminated  glands  were 
prominent,  and  contained  blackish  pigment.  This  diarrhoea  was 
very  obstinate,  and  was  encountered  long  after  all  other  signs  of 
the  Chickahominy  fever  had  vanished  from  view. 

I  have  described  this  fever  because  it  presented  on  a  large  scale 
a  striking  illustration  of  the  typho-malarial  disease.  According 
to  Woodward,  the  fever  belonged  to  the  group  which  was  the 
most  frequent  form  of  camp  fever  during  our  civil  war.  It  con- 
sisted of  mixed  cases,  in  which  the  malarial  and  typhoid  elements 
were  variously  combined  with  each  other  and  with  the  scorbutic 
taint,  now  one,  now  the  other  of  these  elements  preponderating. 
Prominent  among  the  peculiarities  of  the  malady  were  a  decided 
tendency  to  periodicity,  hepatic  tenderness,  with  an  icteroid  hue 
of  the  countenance,  gastric  disturbance,  excessive  enlargement  of 
the  spleen,  a  very  protracted  convalescence,  and  the  appearance 
throughout  of  the  signs  of  a  scorbutic  affection.  The  rose-colored 
rash  and  the  tympanites  of  typhoid  fever  were  generally  absent. 
Diarrhoea  was  ordinarily  very  marked,  and  was  apt  to  be  j)ersistent. 

Now,  except  the  scorbutic  symptoms,  similar  cases  are  seen  by  all 
of  us  to  this  day  throughout  large  portions  of  the  United  States, 
and  the  clinical  manifestations  are  those  of  a  malarial  fever  with 
prominent  typhoid  symptoms.  In  fact,  I  have  already  mentioned 
these  symptoms  when  describing  remittent  fever,  and  I  will  here 
only  add  that  they  may  come  on  early  in  the  case,  as  well  as  develop 
late.  They  are  cases  of  malarial  fever  complicated  with  a  typhoid 
state,  or  more  generally  lapsing  into  it;  and,  while  they  present  the 
.  symptoms  of  a  typhoid  condition,  they  are  lacking  in  the  eruption 
of  enteric  fever,  and  in  the  abdominal  phenomena,  if  we  except 
diarrhoea  and  some  abdominal  swelling,  both  of  which  may,  how- 
ever, also  be  absent.  It  is  these  cases,  malarial  primarily,  in  which 
the  typhoid  condition  shows  itself,  but  in  which  there  is  not  the 
characteristic  lesion  of  typhoid  fever,  to  which,  in  my  judgment. 


880  MEDICAL   DIAGNOSIS. 

the  term  typlio-malarial  should  be  restricted.  Yet  most  cases  that 
are  now  called  tvpho-malarial  fever  are  really  typhoid  fever  asso- 
ciated with  malaria.  They  are  true  typhoid  cases  showing  simply 
unwonted  periodicity  and  greater  enlargement  of  the  spleen  from 
a  malarial  complication,  and  should  not,  I  think,  be  called  typho- 
malaria.  They  arc  simply  cases  of  typhoid  fever  with  malaria, 
and,  if  we  are  to  give  them  a  name,  might  l)e  distinguished  as 
"  malario-ty|)li()ids." 

Yellow  Fever. — This  formidable  malady  takes  its  familiar 
appellation  of  yellow  fever  from  the  yellow  tinge  assumed  during 
its  course  by  the  skin.  It  is  a  distemper  met  with  in  hot  climates 
in  low  and  level  localities  on  the  sea-coast.  Its  source  is  un- 
known ;  it  is  not  malaria,  nor  has  a  characteristic  micro-organism 
been  detected.  All  we  know  certainly  of  the  cause  is,  that  the 
malady  is  due  to  a  specific  poison  which  does  not  exist  without  a 
high  temperature,  and  that  frost  is  its  greatest  enemy. 

Yellow  fever  is  an  affection  of  short  duration  :  it  rarely  lasts  a 
week ;  many  die  on  the  third  or  the  fifth  day  of  the  disease.  It 
has  but  one  paroxysm,  which  is  never  repeated.  This  paroxysm 
may  be  divided  into  three  stages,  which  are  well  marked  in  some 
epidemics,  far  less  so  in  others. 

The  first  stage,  called  that  of  reaction,  is  pre-eminently  the 
febrile  stage.  Its  average  duration  is  from  thirty-six  to  forty- 
eight  hours.  It  usually  begins  suddenly,  and  is  frequently 
ushered  in  by  a  chill.  In  rare  instances  this  is  protracted,  there 
is  great  internal  congestion,  and  death  ensues  before  reaction  oc- 
curs. But  much  more  generally  a  short  chill  is  followed  by 
marked  febrile  excitement.  The  skin  is  harsh  and  hot;  the  pulse 
quick  and  tense,  although  sometimes  it  is  both  easily  compressible 
and  not  much  accelerated ;  indeed,  as  a  rule,  it  declines  before  the 
temperature.  The  face  is  flushed  ;  the  eye  brilliantly  injected, 
yet  watery.  The  patient  is  conscious,  restless,  anxious,  and  com- 
plains much  of  the  torturing  pains  in  his  forehead,  loins,  and 
legs ;  and  the  muscles  of  the  extremities  are  sore  when  moved. 
The  breathing  is  hurried ;  the  stomach  irritable,  the  epigastrium 
painful  on  pressure ;  there  is  great  thirst.  The  bowels  are  con- 
stipated ;  the  stools  very  dark-colored.  The  tongue  is  more  or 
less  coated  and  moist ;  sometimes  it  is  red,  while  at  other  times 
it  remains   natural  throughout  the  disease.      The  febrile  signs 


FEVERS.  881 

increase  toward  evening  and  lessen  toward  morning,  but  do  not 
distinctly  remit  until  after  from  thirty-six  to  fox'ty-cight  hours, 
when  a  remission  does  occur,  or  when,  to  speak  more  correctly, 
the  whole  aspect  of  the  case  changes. 

The  disorder  now  appears  in  its  second  stage;  the  fever  sub- 
sides; the  pulse  falls  and  becomes  easily  compressible;  the  head- 
ache is  relieved ;  the  breathing  is  no  longer  oppressed ;  the  tem- 
perature declines  to  a  little  above  the  norm.  But  the  gastric 
irritability  does  not  wholly  disappear,  and  a  deep  yellow  or 
orange  hue  gradually  tinges  the  eye  and  the  whole  surface  of 
the  body.  The  patient  is  cheerful,  and  wishes  to  get  out  of  bed. 
His  sufferings  may  be,  indeed,  over,  his  convalescence  may  have 
set  in :  after  a  few  dark,  biliary  stools,  the  yellowness  of  the  skin 
fades,  and  he  slowly  gets  well. 

But  it  is  not  often  that  the  disease  relaxes  its  hold  so  easily : 
more  generally  the  deceptive  improvement  does  not  last  a  day, 
and  after  a  brief  lull  the  struggle  for  life  begins.  The  patient 
grows  again  very  uncomfortable  and  anxious.  In  truth,  the 
symptoms  of  the  first  stage  reappear  with  increased  intensity. 
In  addition,  new  signs,  of  the  gravest  import,  show  themselves ; 
some  of  which  are  clearly  due  to  the  corruption  of  the  blood 
that  the  poison  has  silently  effected.  The  pulse  sinks,  and  be- 
comes slow  and  extremely  irregular  and  compressible ;  the  skin  is 
cool,  dry,  dark,  and  in  some  cases  of  a  bronze  hue,  or  livid,  and 
spots  may  occasionally  be  seen  on  its  surface.  The  stomach  is  as 
irritable  as  before,  but  the  act  of  vomiting  is  easier ;  and,  without 
much  retching,  large  quantities  of  altered  blood,  or  "  black  vomit," 
are  ejected.  Blood  oozes  from  the  mouth,  from  the  gums ;  some- 
times from  the  eyes  and  nostrils,  from  the  bowels,  and  from  the 
vagina  ;*  or  hemorrhage  takes  place  into  internal  cavities,  and  the 
blood  is  retain ed.f 

The  phenomena  of  collapse  become  now  more  and  more  un- 
mistakable :  the  black  vomit  often  ceases,  because  the  contractile 
power  of  the  stomach  has  ceased  ;  a  low,  muttering  delirium  sets 
in,  and  the  patient  dies  prostrated.     Yet  the  mind  may  remain 

*  Cases  in  the  epidemic  of  1856-57  at  Lisbon,  reported  upon  by  Lyons, 
London,  1858;  also  by  Alvarengo,  Fievre  jaune  a  Lisbonne,  Paris,  1861. 

f  In  a  case  at  the  Pennsylvania  Hospital  in  1853  the  pericardium  was 
filled  with  blood  resembling  black  vomit. 

56 


882  MEDICAL    DIAGNOSIS. 

cloar  almost  to  the  last,  and  the  strcnoth  be  but  little  impaired. 
Should  reaction  take  i)laee,  recovery  is  only  ver}-  gradual. 

But  W'llow  fever  does  not  at  all  times  and  in  all  localities 
present  precisely  the  same  degree  ol'  intensity  or  the  same  group 
of  symptoms.  '  Sometimes  it  exhibits  frank,  active  febrile  phe- 
nomena ;  at  other  times  there  is  little  febrile  excitement,  but  a 
disposition  to  internal  congestions  and  to  early  prostration.  This 
congestive  form  is  far  more  dangerous  than  the  inflammatory. 
Yet  both  are  highly  destructive.  From  10  up  to  75  per  cent, 
are  the  figures  representing  the  mortality  of  this  fearful  malady. 
Omitting  the  instances  of  an  exceptionally  mild  type,  the  average 
is  calculated,  in  the  elaljorate  work  of  La  Roche,*  to  be  1  in  2.32. 
The  more  rapidly  the  stages  succeed  one  another,  the  more  danger- 
ous the  case.  The  occurrence  of  black  vomit,  of  great  epigastric 
tenderness,  of  hiccough,  of  suppression  of  urine,  of  delirium,  of 
early  jaundice,  of  oppression  in  breathing,  of  convulsions,  of  a 
fiery,  glistening  eye,  and  of  petechia?,  warrants  an  unfavorable 
prognosis.  "  Walking  cases,"  or  those  in  which  the  patients  walk 
about  until  they  suddenly  eject  black  vomit,  always  terminate 
fatally. 

As  regards  the  temperature  in  yellow  fever,  the  maximum  ele- 
vation is  attained  upon  the  first,  second,  and  third  days  of  the 
disease,  ranging  from  102°  to  110°  ;  it  then  falls  in  the  stage  of 
calm,  to  rise  for  the  most  part  again  in  the  stage  of  collapse, 
though  it  never  attains  the  high  temperature  characteristic  of  the 
first  stage,  and  never  rises  so  rapidly.  The  elevated  temperature 
of  the  first  days  may,  however,  continue  with  little  variation  until 
the  sixth  day,  when  the  remission  becomes  marked.  A  com- 
plete remission  usually  happens  on  the  morning  of  the  third  day, 
but  may  not  occur  until  the  fifth  day  or  the  ninth.  Whenever  it 
takes  place,  the  speedy  defervescence  is  very  characteristic.  Even 
in  these  longer  cases  there  is  a  decrease  in  temperature  preceding 
a  fresh  rise,  which  occurs  in  paroxysms  of  two  days  each.  Slight 
rises  in  temperature  are  neither  uncommon  nor  grave  after  the 
marked  fall  in  the  second  stage.  But  when  the  temperature 
rises  rapidly  in  this  stage  of  calm  it  is  of  most  serious  meaning. 
In  the  stage  of  calm  the  absence  of  fever  may  be  complete ;  but 


*  Yellow  Fever,  Philadelphia,  1855. 


FEVERS. 


88.^ 


Fig.  08. 


generally  the  defervescence  is  only  partial  :  a  remission,  therefore, 
rather  than  an  intermission.* 

Yellow  fever  has  rarely  any  complications.  It  may,  how- 
ever, seize  upon  those 
affected  with  other  dis- 
eases. It  has  been  spe- 
cially noticed  that  it  is 
frequently  intercurrent  in 
Surgical  and  obstetrical 
cases,  t 

The  recognition  of  yel- 
low fever  is,  generally 
speaking,  easy.  The  in- 
tense pain  in  the  back, 
limbs,  and  forehead  ;  the 
appearance  of  the  eye ; 
the  color  of  the  skin ; 
the  short  duration  of  the 
febrile  symptoms ;  the 
nausea ;  the  epigastric 
tenderness ;  the  black 
vomit ;  the  albuminuria, 
— constitute  a  group  of 
symptoms  which  unmis- 
takably mark  the  disease. 

But  let  us  look  at  the 
points  of  contrast  which 
yellow  fever  presents  to 
other  affections.  It  dif- 
fers from  plague  by  the 
absence  of  buboes  and  of  carbuncles,  and  by  the  much  more 
frequent  occurrence,  on  the  other  hand,  of  jaundice  and  black 
vomit.     Then,  too,  the  red,  suffused  eye  and  the  single  paroxysm 


Temperature  of  yellow  fever  in  a  case  ending  in  recovery 
recoided  by  Bemiss. 


*  In  addition  to  the  authors  quoted,  see  on  the  temperature  Paget,  JS'ew 
Orleans  Med.  and  Surg.  Journ.,  1873-74;  Bemiss,  Amer.  Journ.  Med.  Sci., 
1880.  The  temperature  charts  of  Naegeli,  of  Rio  Janeiro,  as  given  by  Jac- 
ooud,  Pathologie  interne,  6th  ed.,  1879,  may  also  be  advantageously  studied. 

t  S.  M.  Bemiss,  Clinical  Study  of  Yellow  Fever,  Amer.  Journ.  Med.  Sci., 
April,  1880. 


884  MEDICAL   DIAGNOSIS. 

are  not  witnessed  in  plague.  The  febrile  malady  may  run  on  to 
a  state  of  collapse  as  complete  as  in  Asiatic  cholera  ;  but,  unlike 
this  destructive  disease,  the  symptoms  of  entire  prosti'ation  are 
preceded  by  fever,  and  not  by  vomiting  or  purging  of  rice-water. 

The  lines  of  demarcation  between  the  ordinary  forms  of  con- 
tinned  fever  and  yellow  fever  are  very  broadly  dnn\ii.  It  is  dis- 
tinguished from  rclapsimi  fever  by  the  different  countenance,  by 
the  supra-orbital  pain,  by  the  soon-occurring  remission,  and,  above 
all,  by  the  extreme  rarity  of  a  relapse  and  the  infinitely  greater 
mortality.  To  ti/phoid  fever  it  bears  so  slight  a  resemblance  that 
it  is  scarcely  possible  to  confound  the  two  affections  :  one,  a  short, 
severe  disease,  with  its  peculiar  physiognomy  and  gastric  symp- 
toms ;  the  other,  a  long-continued  malady,  of  low  type,  with  its 
characteristic  eruption  and  enteric  signs.  It  is  only  when  yellow 
fever  is  protracted  beyond  the  ninth  day  that  the  diagnosis  is 
rendered  doubtful ;  and  then  we  have  generally  the  history  to 
guide  to  a  correct  understandino-  of  the  case.  The  likeness  be- 
tween  yellow  fever  and  typhus  is  much  closer.  But  one  is  a  short 
fever,  with  distinct  stages ;  the  other  is  a  longer,  much  more  con- 
tinued fever.  One  has  no  marked  cerebral  symptoms ;  in  the 
other  the  cerebral  symptoms  are  the  most  prominent  feature. 
One  has  but  rarely  an  eruption,  but  often  hemorrhages ;  the 
other  has  always  an  eruption,  and  hardly  ever  hemorrhages. 

The  disease  most  likely  to  be  confounded  with  yellow  fever  is 
bilious  remittent.  In  truth,  the  symptoms  are  very  similar,  and 
many  of  them  differ  only  in  intensity.  The  diagnosis  of  the  milder 
forms  of  yellow  fever  from  remittent  fever  is,  indeed,  extremely 
difficult,  unless  the  epidemic  influences  prevailing  be  taken  into 
account.  Then,  as  is  well  known,  the  affections  may  be  blended, 
and  yellow  fever  become  obviously  periodical  in  its  febrile  phe- 
nomena. The  occurrence  of  black  vomit  is  not  in  itself  a  dis- 
tinctive sign  between  the  two  diseases ;  for  black  vomit  may  be 
absent  in  yellow  fever,  and,  on  the  other  hand,  it  may,  although 
it  rarely  does,  occur  in  remittent  fever,  just  as  it  has  been  known 
to  occur  in  childbed   fever,  in  the  plague,  and  even  in  typhus.* 


*  This  statement  with  reference  to  typhus  fever  is  made  on  the  authority 
of  Stokes.  The  occasional  occurrence  of  black  vomit  in  remittent  fever 
is  admitted  by  manj'  authors.  Some  winters  ago,  a  physician  of  this  city 
brought  to  me,  for  examination,  a  specimen  of  black  vomit  which  had  the 


FEVERS. 


885 


The  least  doubtful  sign  is  derived  from  an  examination  of  the 
urine.  Unlike  what  happens  in  bilious  fever,  a  trace  of  albumen 
appears  in  from  twelve  to  fourteen  hours  after  the  fever  sets  in ; 
then  the  albumen  increases,  and  the  urea  and  the  uric  acid  dimin- 
ish and  gradually  disappear,  as  does  the  bile-pigment.*  The 
more  obvious  the  suffusion  of  the  countenance  in  yellow  fever, 
the  more  marked  and  early  is  the  albuminuria.'!"  In  children, 
albumen  may  be  present  only  in  the  evening  urine. J 

When  yellow  fever  is  well  marked,  it  differs  in  this  way  from 
bilious  remittent : 


Yellow  Fever. 

Of  short  duration,  ending  commonly 
in  from  three  to  seven  days. 

Period  of  incubation  from  five  to  nine 
days. 

A  disease  of  one  paroxysm,  termi- 
nating in  recovery  or  in  collapse. 

Very  severe  nausea  and  vomiting 
thi'oughout ;  early  and  decided  epi- 
gastric tenderness ;  black  vomit. 


Hemorrhages  from  gums  and  various 
parts  of  the  body. 

Tongue  clean,  or  but  slightly  coated ; 
pulse  very  variable,  frequently  be- 
comes slow  in  last  stages. 

Highly -injected,  humid  eyes;  often 
fierce  or  anxious  expression  of  face. 

Supra-orbital  pain,  and  pain  in  back 
and  in  calves  of  the  less. 


Bilious  Kemittent. 
Lasts  nine  days  or  upward. 

Period  of  incubation  very  variable ; 
may  extend  to  months. 

A  disease  of  several  paroxysms,  with 
intervening  remissions. 

Nausea  and  vomiting  not  so  severe, 
and  rarely  as  marked  at  the  onset ; 
neither  as  early  nor  as  constant 
and  decided  epigastric  tenderness; 
vomiting  of  bile  and  of  the  con- 
tents of  the  stomach. 

JSTo  hemorrhagic  tendency. 

Tongue  heavily  coated ;  pulse  varies 
less,  is  always  quick  until  convales- 
cence sets  in. 

Eye  not  peculiar ;  difterent  physiog- 
nomy. 

Headache  ;  sense  of  fulness  in  head ; 
often  no  pain  in  loins  or  in  legs. 


same  microscopical  characters  that  I  have  repeatedly  found  in  the  black 
vomit  of  yellow  fever.  The  patient  vuidoubtedly  had  remittent  fever,  from 
which  he  recovei'ed. 

*  Ballot,  Arch.  Gen.  de  Med.,  Nov.  1869  ;  see,  also,  On  the  Urine  in  Yellow 
Fever,  an  elaborate  paper,  by  Joseph  Jones,  New  Orleans  Med.  and  Surg. 
Journ.,  Jan.  1874;  Berenger-Feraud,  De  la  Fievre  jaune  a  la  Martinique, 
Paris,  1879;  Holland,  Practitioner,  London,  1879,  xxiii.,  and  American  Prac- 
titioner, Sept.  1879;  Sternberg,  New  Orleans  Med.  and  Surg.  Journ.,  1880- 
81,  N.  S.,  viii. 

f  Bemiss,  loc.  cit. 

X  Guiteras,  article  "Yellow  Fever,"  in  Keating's  Cyclopedia  of  the  Dis- 
eases of  Children. 


886 


MEDICAL    DIAGNOSIS. 


Yellow  Fever. 

Very  rarely  deliriuin ;  mind  gener- 
ally clour. 

Urine  generally  contains  albumen ; 
suppression  of  urine  common. 

Little  muscular  prostration  ;  often 
rapid  convalescence  ;  no  sequelaa. 

Almost  certain  imnnmity  after  one 
attack. 

Very  high  nidrtality ;  disease  is  epi- 
demic. 

Treatment  unsatisfactory. 

Autopsy  shows  inflammation  or  very 
great  congestion  of  stomach,  and 
sometimes  ulceration  or  softening. 
Liver  enlarged,  of  a  yellowish  color, 
its  secreting  cells  filled  with  oil- 
globules.  Kidneys  swollen,  in- 
flamed. Heart  often  exhibits  disin- 
tegration of  muscular  fibres. 


Bilious  Eemittent. 
Delirium  frequent  ;  mind  always  dull. 

No  albumen  in  ui-ine ;  suppression  of 
urine  rare. 

Much  greater  muscular  prostration ; 
slow  convalescence  and  tedious  se- 
quelae. 

One  attack  seems  ratlu'i-  to  j)rcdispose 
to  othei-s. 

Slight  mortality ;  disease  more  en- 
demic in  its  nature. 

Ver}^  amenable  to  treatment. 

Autopsy  shows  congestion  of  stom- 
ach ;  more  rarely  inflammation. 
Liver  of  an  olive  or  bronze  hue, 
not  fatty  ;  accumulatinn  of  animal 
starch  in  liver  of  malarial  fever,  no 
grape  sugar.*  Kidneys  unchanged, 
or  simply  congested. 


Eruptive  Fevers. 

The  eruptive  or  exanthematous  fevers  form  a  group  having 
numerous  features  in  common.  They  are  all  characterized  by  a 
period  of  incubation,  during  which  the  poison  lies  dormant  in 
the  system ;  by  a  fever  of  more  or  less  intensity  preceding  the 
eruption ;  by  an  eruption  which  presents  a  distinct  aspect  in  each 
disease,  and  which  pursues  a  definite,  clearly-defined  course  until 
it,  and  with  it  the  febrile  malady,  disappears.  Moreover,  they 
are  all  very  prone  to  occasion  serious  sequelae ;  are  all,  in  the 
main,  disorders  of  childhood ;  rarely  attack  the  same  person 
twice ;  and  are  contagious.  These  remarks  apply  particularly 
to  the  three  chief  exanthematous  fevers :  scarlet  fever,  measles, 
and  smallpox.  In  great ■  part,  too,  they  hold  good  in  regard  to 
erysipelas,  described  here  in  connection  with  the  eruptive  fevers. 

Scarlet  Fever. — Scarlatina  affects  both  children  and  adults, 
and  is  marked  by  great  heat  of  skin,  frequent  pulse,  sore  throat, 
and  an  early  scarlet  eruption.     These  symptoms  are  preceded  by' 
an  uncertain,  generally  a  short,  period  of  incubation,  but  soon 


*  Joseph  Jones,  Medical  and  Surgical  Memoirs,  vol.  ii..  New  Orleans,  1887. 


FEVERS.  887 

exhibit  their  striking  features.  The  febrile  excitement  is  charac- 
teristic ;  the  skin  is  very  hot  and  generally  dry,  and  the  rapidity 
of  the  pulse  so  great  that  often  by  this  sign  alone  we  may,  espe- 
cially in  the  midst  of  an  epidemic,  predict  the  coming  eruption. 
Vomiting,  too,  is  a  frequent  symptom  at  the  beginning  of  the  ill- 
ness. The  temperature  does  not  fall  with  the  appearance  of  the 
eruption,  but  continues  high  until  the  eruption  is  completed  and 
at  its  height.  It  slowly  declines  as  this  declines,  and  with  the 
occurrence  of  desquamation  attains  the  norm ;  but  it  may  persist, 
with  marked  morning  remissions  and  evening  exacerbations, 
when  the  eruption  has  gone  and  during  the  earlier  stages  of  des- 
quamation. 

The  rash  appears  on  the  second  day  of  the  disease.  It  comes 
out  almost  simultaneously  all  over  the  body,  although,  on  close 
scrutiny,  it  may  be  soonest  perceived  on  the  neck  and  the  breast. 
At  first  the  surface  exhibits  an  almost  uniform  red  blush,  which 
disappears  momentarily  on  pressure,  or  rather  pressure  leaves  a 
white  stain  on  the  skin,  which  quickly  again  reddens  from  the 
periphery  to  the  centre.  Soon,  however,  the  eruption  presents  an 
unequal  aspect :  it  is  of  more  vivid  scarlet  hue  in  some  parts  of 
the  body,  as  in  and  around  the  flexures  of  the  joints,  and  is  not 
everywhere  smooth.  Here  and  there  are  seen  elevated  rough 
points  of  darker  tint,  edged  by  the  red  integument,  and  not 
unfrequently  vesicles  containing  a  thin  fluid.  The  skin  is  very 
hot  and  itchy,  and  tumefied,  especially  on  the  hands  and  feet. 
The  eruption  declines  on  the  fourth  or  the  fifth  day ;  by  the 
seventh  or  eighth,  the  cuticle  begins  to  come  away  in  large  flakes. 
Sometimes  the  rash,  when  at  its  height,  recedes  and  then  appears 
again.  In  malignant  cases  it  comes  out  late,  and  is  either  pale 
and  indistinct  or  dark  and  livid.  In  some  instances  it  is  want- 
ing. Some  years  ago,  I  saw  this  "  scarlatina  sine  exanthemate" 
in  a  lady,  who,  watching  over  the  sick-bed  of  her  daughter, 
contracted  the  disease  and  went  regularly  through  it,  even  to  its 
sequelse  of  disorder  of  the  kidneys  and  swelling  of  the  salivary 
glands,  but  in  whom  not  a  trace  of  an  eruption  could  be  detected. 

The  sore  throat  of  scarlatina  is  almost  as  constant  and  as  char- 
acteristic as  the  scarlet  rash.  It  shows  itself  early,  sometimes 
before  the  eruption,  and  rarely  waits  until  the  third  day  of  the 
complaint.      At  first   the  throat-affection  consists  in  a  diffused 


888  MEDICAL    DIAGNOSIS, 

redness  extending  over  the  tonsils,  palate,  and  half-arelies,  and 
iua  swelling  of  the  tonsils:  the  patient  complains  of  pain  in  his 
throat,  augmented  by  pressure  and  by  swallowing,  and  of  stiffness 
of  the  muscles  of  the  neck.  After  a  few  days,  if  the  disorder 
be  severe,  irritating  discharges  occur  from  the  inflamed  surfaces, 
and  patches  of  false  membrane  and  superficial  ulcerations  are 
seen  in  the  fauces.  The  glands  of  the  angle  of  the  jaw  become 
much  tumefied,  and,  by  pressing  on  the  cervical  vessels,  produce  a 
tendency  to  drowsiness  and  stupor.  These  are  grave  symptoms ; 
their  occurrence,  indeed,  is  indicative  of  one  of  the  main  dangers 
in  these  "  anginose"  cases  of  the  disease. 

The  false  membranes  which  are  developed  last  about  five  or  six 
days ;  they  form  as  well  as  reform  in  patches,  and  are  very  easily 
removed.  Sometimes  they  extend  to  the  larynx  ;  but  this  does 
not  often  happen,  and,  even  when  it  does,  the  symptoms  of  croup, 
in  the  opinion  of  Barthez  and  Rilliet,  do  not  arise.  The  acid 
discharges  and  the  decomposing  membranes  often  occasion  a  most 
fetid  breath,  and,  by  being  swallowed,  a  persistent  diarrhoea. 

The  tongue  has  a  peculiar  look.  At  first  it  is  thickly  coated, 
and  its  borders  only  are  red ;  but  soon  the  fur  is  cast  off,  and  the 
whole  organ  becomes  very  red  and  its  papillae  prominent.  After 
it  has  presented  this  appearance  for  six  or  eight  days,  it  returns 
to  its  normal  condition.  In  bad  cases  it  is  extremely  dry  and  of 
a  brownish  hue. 

In  children  the  disease  frequently  sets  in  with  convulsions.  In 
truth,  cerebral  symptoms  of  one  kind  or  another  are  not  uncommon 
at  all  stages  of  the  malady  ;  }'et  great  differences  are  observed,  in 
this  respect,  in  different  epidemics.  In  some  cases  of  malignant 
character,  the  vomiting,  the  screams,  the  grinding  of  the  teeth, 
the  occurrence  of  delirium  and  insomnia,  make  the  attack  look, 
at  the  onset,  like  one  of  acute  meningitis ;  but  the  eruption  soon 
sets  all  doubt  at  rest,  and,  even  before  it  is  noticed,  the  great  heat 
of  the  skin  and  the  extreme  rapidity  of  the  pulse  point  to  the 
source  of  the  mischief.  The  nervous  symptoms  in  these  dan- 
gerous instances  of  the  affection  do  not,  however,  cease  with  the 
eruption ;  they  may  last  to  the  end  of  the  malady.  Sometimes 
they  are  not  noticed  until  late  in  the  disorder,  and  after  the 
period  of  desquamation  has  fully  begun  ;  but  the  convulsions 
and  stupor — for  these  are  the  morbid  manifestations  then  more 


FEVERS.  889 

specially  encountered — arc  owing  rather  to  a  diseased  state  of 
the  kidneys  that  has  been  induced,  than  to  the  immediate  effect 
of  the  fever  poison. 

Occasionally  some  of  the  larger  joints  swell  up,  and  present 
the  appearance  of  subacute  rheumatism.  The  joints  are  not, 
however,  very  painful  on  pressure,  and  generally  only  two  or 
three  are  enlarged.  This  form  of  rheumatism  is  evidently  owing 
to  the  retention  in  the  blood  of  some  morbid  material,  and  would 
seem  to  simulate  ordinary  acute  articular  rheumatism  in  present- 
ing endocarditis  and  pericarditis  as  complications.* 

Further  complications  of  the  disease  are  dropsies,  passage  of 
blood  from  the  kidneys,  pleurisy,  tendency  to  gangrene,  oedema 
of  the  glottis,  diphtheria,t  and  a  very  low  state  of  the  system. 
These  complications  are  not  apt  to  arise  until  at  or  soon  after  the 
period  of  desquamation ;  sometimes  they  lead  to  long-continued 
disorder,  and  become  thus  the  most  hazardous  of  the  sequelae. 
Other  consequences  of  the  affection,  lasting,  it  may  be,  for  years 
after  the  febrile  attack,  are  a  tendency  to  boils,  swelling  of  the 
parotid  and  of  the  lymphatic  glands  of  the  neck,  diarrhoea, 
chronic  inflammation  of  the  eyelids,  and  deafness  from  inflamma- 
tion extending  up  the  Eustachian  tube  to  the  membrane  of  the 
tympanum,  or  from  suppurative  destruction  of  portions  of  the 
ear.  Epilepsy  is  also  a  sequel  of  scarlet  fever,  more  cases  being 
consecutive  to  it  than  to  all  other  acute  diseases  combined. | 
Optic  neuritis  may  follow  scarlet  fever,  without  organic  change 
in  the  brain. 

Of  all  these  morbid  states,  dropsy  is  the  most  common.  The 
effusion  of  fluid  may  be  caused  by  the  altered  state  of  the  blood ; 
but  much  more  generally  it  is  owing  to  the  poison  producing  an 
acute  desquamative  nephritis  :  albumen,  tube-casts,  epithelial  cells, 
and  sometimes  blood,  are  found  in  the  scanty  urine  ;  and  we  meet 
with  severe  headache,  great  restlessness,  and  oedema  of  the  face  and 
extremities,  as  the  attending  symptoms.  Still,  notwithstanding 
these  grave  phenomena,  the  majority  of  the  cases  recover,  and 
the  kidneys  are  rarely  permanently  injured. 

*  Scott  Alison,  Medical  Gazette,  1845. 

t  Trousseau,  Clinique  Medicale,  tome  i. ;  see  also  article  "  Scarlet  Fever"  in 
Ziemssen's  Cyclopedia  and  in  Amer.  Syst.  of  Pract.  Med. 
%  Gowers,  Diseases  of  the  Nervous  System. 


890  MEDICAL    DIAGNOSIS. 

The  dropsy  is  apt  to  show  itself  between  the  tenth  and  tlie  twen- 
tieth day  of  the  niahidy.  The  albuminous  eondition  of  the  urine 
may  ])recedo  it  by  several  days ;  yet  dropsy  may  happen  without 
albuminuria,*  especially  in  some  epidemics,  and  albumen  in  the 
urine  is  not  always  associated  with  dropsy.  In  most  aises  of  scar- 
latina it  is  found  at  some  period  of  the  disease  for  a  short  time 
and  in  small  quantities ;  but  this  transitory  albuminuria  is  not, 
like  the  albuminuria  coexisting  with  marked  anasarca,  connected 
with  many  tube-casts  in  the  urine  and  numerous  epithelial  cells. 

The  state  of  exhaustion  noticeable  at  the  close  of  the  fever  and 
while  desquamation  is  still  going  on  is  at  times  great, — so  great 
that,  in  young  persons  especially,  the  case  wears  the  look  of 
typhoid  fever.  And  the  resemblance  is  heightened  by  the  occur- 
rence of  diarrhoea  associated  with  a  swelling  of  the  solitary  and 
agminated  glands.  But  the  signs  of  desquamation,  the  sore  throat, 
the  enlargement  of  the  cervical  glands,  and  the  history  of  the 
aifection  furnish  distinctive  marks  of  the  utmost  value. 

The  statements  that  have  just  been  made  concerning  the  diverse 
complications  of  the  malady  are  mainly  of  interest  on  account  of 
their  exhibiting  the  intricate  diagnostic  questions  which  may  arise. 
Of  the  recognition  of  the  disorder  during  the  febrile  stage  it  is 
not  necessary  to  say  much,  as  ordinarily  it  is  not  difficult.  The 
distinction  between  it  and  the  other  exanthematous  fevers  may 
be  seen  by  glancing  at  the  table,  to  which  a  place  is  elsewhere 
assigned.  I  shall  only  here  mention,  as  bearing  upon  the  differ- 
ences between  scarlet  fever  and  measles,  that  cases  are  occasionally 
encountered  in  which  the  eruption  alone  is  too  ill  defined  to  be- 
come the  sole  basis  of  an  opinion,  and  that  then  we  have  to  lay 
the  greatest  stress  on  the  presence  or  absence  of  catarrhal  symp- 
toms and  sore  throat,  and  on  the  march  of  the  symptoms.  So, 
too,  with  reference  to  smallpox.  The  rash  preceding  the  forma- 
tion of  the  pustules  may  have  so  strong  a  resemblance  to  that  of 
scarlet  fever  that  a  scrutiny  of  all  the  attending  circumstances,  and 
a  careful  watching  of  the  eruption  for  at  least  a  day,  are  requisite 
to  the  detection  of  the  true  nature  of  the  case.f 

*  Gee,  in  Russell  Eeynolds's  System  of  Medicine;  also  Quincke,  Berlin. 
Klin.  Woch.,  1882,  No.  27;  Dyce  Duckworth,  St.  Earth.  Hosp.  Rep.,  1883. 

t  The  disorders  may  also  be  combined.  See  the  cases  of  Marson,  Medico- 
Chirurg.  Transact.,  vol.  xxx. 


FEVERS.  891 

An  erythematous  rash,  ajDpearing  in  blotches  everywhere  except 
on  the  face,  has  been  noticed  in  membranous  croup  and  in  laryngeal 
diphtheria  after  the  operation  of  traciieotoniy.*  Ijiit  it  is  very  ir- 
regular, runs  a  rapid  course,  and  is  not  followed  by  desquamation ; 
a  point,  it  may  be  here  mentioned,  distinguishing  all  tlie  forms 
of  irregular  rashes  happening  at  times — though  very  rarely — in 
diphtheria,  from  the  scarlet  fever  eruption.  As  the  result  of  gon- 
orrhoea we  may  have  symptoms  of  a  low  fever  associated  with  a 
cutaneous  rash  like  that  of  scarlet  fever.  The  history  and  progress 
of  the  case  chiefly  distinguish  this  pseudo-scarlatina.'f 

Like  measles,  scarlatina  may  be  mistaken  for  that  curious  form 
of  eruptive  fever  called  rubella  or  rubeola.  But  this  really  more 
closely  resembles  measles,  and  in  examining  it  presently  the  dif- 
ferences between  it  and  scarlet  fever  will  become  apparent. 

An  affection  with  several  features  like  scarlatina  is  breakbone 
fever,  or  dengue.  The  points  of  dissimilarity  may  be  learned  by 
referring  to  the  description  of  the  malady  farther  on  given. 

Scarlet  fever  may  go  on  concurrently  with  other  fevers.  It 
has  been  observed  with  typhoid  fever,  and  with  varicella,^  and 
intercurrent  in  surgical  operations. 

Measles. — The  symptoms  precursory  to  the  specific  eruption 
of  this  affection  are  fever,  watery  eyes,  frequent  sneezing,  flow 
from  the  nose,  and  cough  ;  in  fact,  all  the  manifestations  of  an 
acute  coryza  or  catarrh.  To  these  diarrhoea  is  in  many  instances 
added,  indicating  a  simultaneous  irritation  of  the  intestinal  mucous 
membrane.  On  the  fourth  day  after  the  beginning  of  the  morbid 
signs,  a  rash  is  perceived  on  the  face  and  neck ;  thence  it  con- 
tinues to  extend,  until,  in  the  course  of  two  or  three  days,  the 
whole  body  is  covered.  The  temperature  during  the  first  day  of 
the  disease  is  generally  from  102°  to  103°  ;  if  higher,  the  attack 
is  likely  to  be  severe.  On  the  second  or  third  day — usually  on 
the  second,  when  it  may  be  but  98.6°  or  99° — it  is  markedly  lower, 
and  it  rises  again  on  the  evening  of  the  third  or  on  the  fourth  day 
to  decided  fever  heat.  The  temperature  does  not  at  once  decline 
with  the  rash.     Indeed,  it  is  apt  to  go  on  rising  for  twenty-four 

*  Bericht  des  k.  k.  Krankenhauses,"Weiden,  I860. 

t  Ballot,  Arch.  Gen.  de  Med.,  Sept.,  1882.  The  same  author  calls  attention 
to  u  puerperal  pseudo-rubeola,  a  false  measles,  from  blood-infection. 

X  Church,  St.  Barthol.  Hosp.  Eep.,  1881 ;  Lond.  Med.  Kecord,  Nov.  1883. 


892  MEDKWI.    DIAGNOSIS. 

to  tliirty-six  hours;  the  occinTence  of  the  eruption  docs  not  alle- 
viate the  febrile  symptoms ;  on  the  contrary,  >yhile  it  is  spreading 
to  the  tYnnk  and  the  lower  extremities,  the  constitutional  disturb- 
ance lasts,  or  more  generally  increases.  But  as  soon  as  the  rash 
has  fully  reached  its  height,  the  defervescence  is  rapid ;  and  from 
the  fifth  to  the  seventh  day  of  the  disease  the  temperature  sinks 
until  it  is  but  little  above  the  norm.  By  the  ninth  day  of  the 
disease  both  fever  and  rash  have  left.  Frequently  then  the  cuti- 
cle comes  a^vay  in  fine  scales,  and  this  desquamation  is  attended 
\vith  very  annoying  itching.  The  patient,  no\y  that  he  is  conva- 
lescent, sho^vs  his  illness :  he  is  pale  and  somewhat  emaciated. 
Often  he  still  coughs,  and  his  eyes  are  slightly  inflamed.  These 
signs  are  not  unusually  the  last  to  disappear. 

Of  all  the  symptoms  mentioned,  two  are,  in  a  diagnostic  sense, 
of  pre-eminent  importance :  the  catarrh  and  the  eruption. 

The  catarrh  is  nearly  constant.  It  is  true  that  a  variety  of 
measles  is  recognized, — "  rubeola  sine  catarrho ;"  but  this  is  very 
rare.  Generally  speaking,  the  coryza  and  catarrh  decline  with 
the  eruption  ;  occasionally,  however,  they  remain  for  some  time 
after  the  rash  has  left.  The  feature  which  distinguishes  these 
catarrhal  symptoms  from  those  of  influenza  consists  in  the  erup- 
tion :  before  this  happens,  the  diagnosis  is  uncei'tain,  though  we 
may  often  suspect  measles  by  the  look  of  the  face,  the  greater 
intensity  of  the  febrile  signs,  and  the  knowledge  that  the  disease 
is  prevailing  in  the  community. 

The  eruption  is  peculiar  :  it  consists  of  slightly-raised  red  spots, 
which  coalesce  and  form  blotches  of  an  irregular,  crescentic  shape ; 
between  these  blotches  the  skin  is  of  natural  color.  The  erup- 
tion disappears  first  from  the  face ;  in  other  words,  it  disappears 
in  the  same  order  in  which  it  appeared.  As  it  fades,  which  it 
does  on  the  third  or  fourth  day  of  its  appearance,  it  becomes 
brownish,  and  subsequently  of  a  yellowish  tint.  In  its  earliest 
stages  it  is  similar  to  the  papulre  of  smallpox ;  and  this  similarity 
may  be  heightened  by  its  being  mixed,  as  it  sometimes  is,  with  a 
few  miliary  vesicles.  But  after  the  first  day  of  the  rash  there  is 
little  room  for  doubt.  In  the  one  case  the  spots  remain  as  they 
were  ;  in  the  other,  they  change  into  pustules. 

A  question  may  sometimes  arise  as  to  whether  the  eruption  be 
that  of  typhus  fever  or  of  measles.     Both  are  coarse,  both  often 


FEVERS.  893 

not  unlike  in  color,  and  both  may  be  developed  about  the  same 
time.  Generally  speaking,  however,  the  eruption  of  typhus  fever 
shows  itself  several  days  later  than  the  rash  of  measles ;  and, 
although  coarse,  it  is  not  cresccntic,  and  is  found  on  the  trunk 
and  extremities  rather  than  upon  the  face.  Moreover,  the  l)hysi- 
ognomy,  the  excessive  prostration  of  strength,  and  the  marked 
cerebral  symptoms  of  the  low  fever  are  such  as  to  render  a  <lif- 
ferential  diagnosis  seldom  difficult. 

Measles  is  usually  met  with  in  children  ;  but  it  may  be  en- 
countered in  adults,  especially  among  soldiers,  and  is  in  adults 
a  much  more  severe  complaint  than  in  children.  In  the  latter 
it  is  not  an  alarming  disease.  Only  occasionally  does  it  occur 
in  epidemics  which  present  a  malignant  character.  Its  greatest 
danger  commonly  consists  in  the  eruption  disappearing  prema- 
turely or  appearing  but  partially,  and  in  the  severity  of  the  tho- 
racic complications.  These  are  either  acute  bronchitis  or  acute 
pneumonia. 

Acute  bronchitis  may  occur  at  any  period  of  the  disorder,  and 
involve  the  finer  tubes.  But  it  does  not  generally  set  in  with 
severity  until  the  eruption  has  reached  its  height  or  is  beginning 
to  fade.  In  young  children,  symptoms  of  inflammation  of  the 
larynx,  or  of  croup,  are  at  the  same  period  apt  to  manifest  them- 
selves. Acute  injlammaiion  of  the  lung,  too,  either  croupous  or 
catarrhal,  the  latter  most  often,  is  met  with  at  this  stage  of  the 
malady,  or  sometimes  even  after  convalescence  has  apparently 
begun.  We  may  suspect  that  mischief  is  going  on  within  the 
chest,  if  the  breathing  be  very  oppressed  and  the  pulse  continue 
to  be  rapid  ;  but,  so  as  to  detect  early  the  hazardous  and  insidious 
complication,  we  have  to  depend  chiefly  on  physical  exploration. 

Occasionally  the  thoracic  affection  leaves  a  chronic  bronchial 
disease,  or  a  persistent  coftgh  and  night-sweats  point  to  the  de- 
velopment of  tubercles.  It  may,  in  individual  cases,  be  ex- 
tremely difficult  to  decide  with  which  of  these  morbid  states  we 
have  to  deal.  Emaciation  and  a  chronic  cough  are  found  in 
both  chronic  bronchitis  and  phthisis ;  and  the  physical  signs  of 
tubercular  consumption  are,  in  children,  notoriously  ill  defined 
and  untrustworthy.  Then,  the  nummular  sputum  may  occur 
in  the  bronchitis  of  measles.  We  may,  therefore,  be  obliged  to 
await  the  progress  of  the  abnormal  phenomena  before  coming 


894  MEDICAL    DIAGNOSIS. 

to  a  ilotinite  conclusion.  The  pneumonia  of  measles  has  been 
attributed  to  the  bacteria  which  are  found  in  the  nasal  mucus 
in  mea^^les  penetrating  in  large  numbers  into  the  lung  and  there 
setting  up  inflammation,''' 

At  times  we  meet  with  anumah)us  forms  of  measles.  There  is 
a  kind  of  measles  with  a  papular  eruption  like  ordinary  measles, 
but  distinguished  from  it  by  the  papula?  not  being  arranged  in 
cresccntit!  clusters,  being  less  obvious,  and  not  a])pearing  at  all,  or 
showing  themselves  but  imperfectly,  on  the  limbs.  The  patches 
are  of  dusky  hue,  and  there  is  no  distinct  sore  throat,  but  con- 
siderable constitutional  disturbance.  This  "  rubeola  nothct"  pre- 
vailed extensively  in  London  about  twenty-five  years  since. f  A 
similar  anomalous  exanthem  was  common  in  Philadelphia  during 
the  winter  of  18G5-66,  occurring  at  a  time  when  both  measles 
and  scarlatina  were  frequent,  and  particularly  the  former.  The 
eruption,  more  partially  papular  than  that  of  measles,  but  of  dark 
hue  like  it,  was  principally  confined  to  the  face.  It  appeared 
at  the  end  of  the  first  or  on  the  second  day  of  a  slight  malaise ; 
though  in  some  instances  I  saw  there  had  been  a  marked  chill  at 
the  beginning  of  the  complaint,  in  others  the  rash  was  the  first 
sign  of  disease  attracting  attention.  There  was  little  constitutional 
disturbance,  a  slight  watery  appearance  of  the  eye,  no  sore  throat, 
or  a  mere  faucial  reddening,  and  cough ;  but  this  symptom  was 
not  constant.  The  eruption,  which  occurred  chiefly  in  patches, 
not,  however,  distinct  and  crescentic,  lasted  from  five  to  seven  days, 
gradually  fading,  and  not  being  followed  by  desquamation.  In 
only  one  instance  did  I  observe  a  peeling  of  the  cuticle,  and  this 
happened  on  the  hands  and  feet.  An  almost  invariable  sequel 
was  swelling  of  the  cervical  glands.  The  urine  in  the  cases  I 
examined  contained  no  albumen,  and  convalescence  was  rapid. 
In  one  family  I  attended,  the  exanthem  attacked  three  out  of 
four  children,  all  of  whom  had  had  measles  two  years  previously. 

Perhaps  these  anomalous  forms  of  measles  are  rather  varie- 
ties of  rubella  than  of  measles.  An  affection  formerly  very 
common,  miliary  fever,  would  be  also  a  source  of  much  confusion 
were  it  in  our  day  often  encountered.     But  epidemics  of  miliaria 


*  Cornil  et  Babes,  Arch,  de  Phys.,  Aug.  1883. 
t  Babington,  Lancet,  May  7,  1864. 


FEVERS.  895 

are  now  extremely  rare.  Yet  we  know  that  it  is  a  disorder  witli  a 
prodromal  stage  of  two  or  three  days,  during  which  great  irrita- 
tion of  the  skin,  debility,  and  a  feeling  of  siiifocation  are  usual. 
The  marked  disease  begins  with  profuse  sweating  and  with  severe 
fever,  and  prsecordial  and  epigastric  distress.  These  symptoms 
last  until  the  appearance  of  the  rash,  generally  on  the  third  or 
the  fourth  day,  though  sometimes  not  until  much  later,  and  then, 
as  a  rule,  slowly  subside.  The  rash  appears  first  upon  the  neck 
and  the  breast,  and  consists  of  numerous  round  or  irregular  spots, 
in  the  centre  of  which  vesicles  arise  that  finally  burst  and  form 
crusts.  The  disease  ends  with  desquamation  and  generally  in  a 
slow  convalescence.  The  sweating,  the  oppression  and  precordial 
pain,  and  the  peculiar  eruption  distinguish  chiefly  this  epidemic 
disease  from  measles. 

Rubella. — The  most  striking  resemblance  to  measles  is  fur- 
nished by  rubella,  or  rubeola.  This,  also  called  by  the  Germaas 
rotheln,  or  "  fire-measles,"  and  often  spoken  of  as  ''  German 
measles"  or  "  French  measles,"  is  not  a  hybrid  of  measles  and 
of  scarlet  fever,  but  a  special  exanthem,  which  occurs  in  epi- 
demics. It  displays  a  red  eruption,  ushered  in  by  a  chill,  followed 
by  slight  fever,  which  is  accompanied  by  coryza,  cough,  and  sore 
throat.  The  fever  prior  to  the  eruption  lasts  for  two  or  three  days, 
but  this  is  far  from  constant ;  indeed,  it  often  does  not  last  more 
than  half  a  day,  or  it  may  be  of  a  week's  duration.*  The  tem- 
perature rarely  exceeds  102.5°.  The  rash  may  come  out  all  over 
at  once,  or  spread  in  a  day  or  two  over  the  body ;  it  generally 
appears  first  on  the  face  and  neck.  It  is  most  distinct  on  the 
face,  the  scalp,  the  neck,  and  the  trunk,  being  more  scattered  on 
the  extremities  ;  it  is  specially  distinct  about  the  mouth.  It  first 
resembles  measles,  but  the  spots  are  round  or  oval,  and  smaller  and 
paler,  and  they  soon  run  together  in  irregular  patches,  unlike  the 
well-defined  crescentic  eruption  of  measles;  they  show  no  tendency, 
however,  to  become  generally  confluent.  The  patches  are  of  vari- 
able size,  and,  unlike  the  rash  of  scarlatina,  are  surrounded  by 
healthy  skin ;  small  spots  range  themselves  around  the  large  ones. 
They  are  of  deepest  color  in  the  centre,  but  not  bright-colored  as 
in  measles,  nor  of  the  dark  red  of  severe  scarlatina,  are  elevated, 

*  Edwards,  article  "  Rubella,"  in  Keating 's  Cvcl.  of  Diseases  of  Children. 


896  MEDICAL    DIAGNOSIS. 

and  very  much  inHucnccd  by  pressure.  The  eruption  lasts  ordi- 
narily four  or  five  days,  but  in  severe  cases  eight  or  ten.  It 
gradually  fades,  but  it  may  happen  that  it  fades  on  the  face 
before  it  has  fairly  come  out  on  the  legs,  and  desquamation  may 
ensue,  though  the  scales  are  small,  and  never  in  size  like  those 
of  scarlet  fever.  During  the  continuance  of  the  rash,  which  is 
attended  with  much  itching,  the  general  symptoms  are  much 
aggravated,  except  the  fever,  which  indeed  may  be  perceptible 
only  at  the  beginning  of  the  affection ;  the  sore  throat  and  catarrh 
mav  be  severe,  and  attended  with  hoarseness  and  with  inability  to 
swallow ;  there  are  congestion  of  the  conjunctivae  and  pain  in  the 
eyes.  Osborn  has  called  attention  to  enlargement  of  the  small 
glands  at  the  edge  of  the  hair  on  the  postero-lateral  sides  of  the 
neck  as  a  pathognomonic  sign.*  As  the  rash  fades,  the  other 
symptoms  subside.  Swelling  and  even  suppuration  of  the  cer- 
vical glands  are  not  uncommon  sequelre. 

The  disease  may  be  very  difficult  to  distinguish  from  measles, 
except  when  it  is  epidemic  and  affects  those  who  have  already 
had  measles.  The  more  sudden  onset,  often  almost  feverless,  the 
milder  course  of  the  complaint,  and  the  peculiarities  of  the  erup- 
tion already  spoken  of,  are  guides  in  separating  individual  cases. 
But  the  appearance  of  the  rash  may  be  ill  defined  and  very 
misleading.  Typhus  fever,  at  least  as  regards  the  eruption,  has 
some  similarity  to  German  measles.  But  the  severe  fever,  the 
far  greater  gravity  of  the  constitutional  symptoms,  the  rash  not 
appearing  on  the  face,  and  the  absence  of  catarrhal  symptoms,  are 
strikino;lv  unlike  the  latter  affection. 

The  disease  is  contagious,  and  affects  especially  children ;  it  is 
extremely  uncommon  after  forty  years  of  age.  Second  attacks 
are  also  very  rare. 

Smallpox. — Smallpox,  or  variola,  attacks  both  children  and 
adults.  It  is  a  highly-contagious  malady,  spreading  rapidly 
among  those  unprotected  by  vaccination,  and  among  masses  of 
men  :  hence  its  presence  on  board  ship  or  in  camps  is  especially 
to  be  feared. 

The  chief  symptoms  of  the  stage  of  invasion  are  chills,  fever, 
and  pain  in  the  back.     The  fever  runs  very  high,  and  exacerbates 


*  Weekly  Med.  Eev.,  Dec.  24,  1887. 


FEVERS.  897 

markedly  toward  evening.  Tlic  pain  in  the  back  is  sev^ere,  par- 
ticularly in  grave  cases;  it  may  be  attended  l)y  pain  in  the  limbs 
like  those  of  rheumatism ;  there  are  also  nausea,  vomiting,  head- 
ache, and  great  restlessness.  All  these  symptoms  subside  at  the 
end  of  the  third  or  on  the  fourth  day,  when  an  eruption  shows 
itself  on  the  lips  and  forehead,  and  soon  extends  to  the  trunk, 
and  from  the  trunk  to  the  extremities ;  and  with  the  appear- 
ance and  the  spread  of  the  eruption  there  is  a  very  decided  fall  in 
temperature. 

At  first  the  eruption  has  the  appearance  of  napulse ;  but  on  the 
second  and  third  days  the  coarse  spots  undergo  a  decided  change. 
At  the  top  of  each  papule  appears  a  vesicle,  which  gradually 
becomes  larger,  and  fills  up  with  a  milky,  thick  fluid ;  in  short, 
becomes  a  pustule.  By  the  fifth  or  sixth  day  this  change  has 
been  fully  accomplished,  and  the  pustules  are  spheroidal  and  lose 
the  umbilicated  look  which  they  had  while  forming.  On  the 
eighth  day  matter  begins  to  ooze  from  their  edges,  and  a  second- 
ary fever  sets  in,  lasting  for  three  or  four  days, — until,  indeed,  all 
the  pustules  are  broken;  this  secondary  fever  is  sometimes  ushered 
in  by  a  chill ;  it  is  of  remittent  type,  and  the  evening  temperature 
marks  between  103°  and  105°.  By  the  time  it  subsides,  crusts 
form  where  previously  there  had  been  pustules ;  and  as  these 
crusts  dry  and  fall  off,  the  skin  beneath  is  seen  to  be  of  a  red 
color,  which  only  very  gradually  fades,  and  here  and  there  are 
noticed  those  scars  and  pits  which  the  patient  carries  during  the 
remainder  of  his  life.  Preceding  the  characteristic  eruption  in 
smallpox  a  red  rash  is  at  times  noticed  in  the  pubic  and  the 
inguinal  regions,  which  is  very  significant.* 

When  the  pustules  are  in  great  abundance,  they  run  together, 
constituting  confluent  smallpox.  The  eruption  may  be  discovered 
a  day  earlier  than  in  the  discrete  form,  and  the  rough,  red  blotches 
are  often  so  thickly  clustered  as  to  give  a  uniformly  red  aspect  to 
the  whole  surface.  When  the  pustules  completely  fill  up,  w^hole 
portions  of  the  face  or  of  the  trunk  seem  to  be  covered  by  one 
extensive  pustule,  which  gradually  dries  into  a  continuous  brown- 
ish and  most  disfiguring  crust.  While  the  process  of  maturation 
is  going  on,  the  features  are  observed  to  be  greatly  swollen ;  the 

*  Fagge,  Practice  of  Medicine,  vol.  i.  p.  223. 
57 


sds 


MEDICAL    DIAGNOSIS. 


eves  may  be  hidden  Iroin  view;  the  nose  and  lips  are  tumid. 
The  patient  eomplains  of  the  tension  of  the  skin,  and  not  unfre- 
quently  of  sore  throat  and  of  a  steady  liow  of  saliva  from  the 
mouth.*     The  secondarv  fever  is  viok'ut,  far  more  so  than  in 


Fig.  09. 


Temperature  in  the  severe  form  of  variola;  death  during  the  secondary  fever. 
(After  Wunderlich.) 

discrete  vai'iola.     It  may  not  show  itself  until  a  day  or  two  later, 
but  ]a.sts  longer,  shows  a  higher  temperature,  and  is  the  period  of 


*  Salivation  may  also  be  met  with  in  measles,  and  sometimes  in  other 
acute  aft'ections.  Thus,  Tilt  (Change  of  Life,  3d  edit.)  tells  us  that  he  has 
observed  it  in  connection  with  intense  cerebral  neuralgia  in  women  whose 
menstrual  functions  are  cettsing. 


FEVERS.  899 

danger,  since  it  is  at  this  time  that  deatli  is  most  apt  to  happen. 
Death  is  sometimes  preceded  by  extraordinarily  high  temperature, 
108°  or  upwards. 

A  fatal  issue  is  often  preceded  by  a  dry  tongue,  by  delirium,  and 
by  great  restlessness ;  by  what,  in  fact,  are  called  typhoid  symji- 
toms.  Sometimes  it  is  brought  about  by  attacks  of  dysentery  or 
of  diarrhoea,  by  passive  hemorrhages,  by  affections  of  the  larynx 
or  the  trachea,  or  by  acute  endocarditis ;  *  by  some  complications, 
therefore,  which  the  worn  and  irritated  frame  is  unable  to  with- 
stand. Now  and  then  death  takes  place  from  supervening  pleu- 
risy or  pneumonia  or  bronchitis  ;  but  an  unfortunate  termination 
from  maladies  of  the  respiratory  organs  does  not  occur  only  in  the 
secondary  fever,  as  these  affections  are  also  encountered  during 
the  period  of  eruption.  Sometimes  the  patient  sinks  at  the  very 
onset  of  the  disease.  In  these  malignant  cases,  mostly  met  with 
at  the  beginning  of  an  epidemic,  he  dies  from  the  virulence  of 
the  poison.  He  is  stupid,  delirious ;  the  eruption  seems  as  it 
were  to  struggle  to  reach  the  surface,  is  ill  defined  and  of  a 
livid  hue,  and  may  fail  to  appear  until  after  death. 

Smallpox  is  occasionally  met  with  during  the  progress  of 
other  disorders,  blending  its  symptoms  with  those  of  the  com- 
plaint to  which  it  becomes  superadded.  It  is  thus  found  as  an 
intercurrent  affection  in  typhoid  fever,  in  typhus,  in  scarlet  fever, 
and  in  measles ;  yet  even  then  there  is  no  difficulty  in  recognizing 
its  peculiar  traits, — its  lumbar  pain  and  characteristic  eruption. 
Ordinarily  the  detection  of  variola  is  extremely  easy,  except  at  its 
onset.  But  the  points  of  similarity  it  may  present,  in  its  early 
stages,  to  typhus  fever,  to  erysipelas,  and  to  several  other  diseases, 
have  been  already  discussed,  and  need  not  be  repeated ;  we  have 
often  to  wait  the  course  of  the  eruption  before  framing  a  positive 
diagnosis  from  the  symptoms  alone,  and  without  taking  into 
account  the  epidemic  influences  prevailing.  When  the  disorder 
is  fully  developed,  all  difficulty  in  its  diagnosis  ceases.  Let  us 
here  look  at  the  marks  of  distinction  between  it  and  the  other 
principal  eruptive  fevers,  premising  the  statement  that  in  the 
period  of  invasion  the  pain  in  the  loins  is  the  most  significant 
differential  sign. 

*  Qiiinquad,  Arch.  Gen.  de  Med.,  Sept.  1870. 


900 


MEDICAL  DIAGNOSIS. 


Table  exhibitino  the  Differences  betweex  Scarlet  Fever, 
Mea.sles,  and  Smallpox. 


Scarlet  Fever. 

Period  of  incubation 
generally  a  week  or 
less. 

Fever,  with  very  fre- 
quent pulse  ;  persists 
unabated  during  erup- 
tion. 

Eruption  on  second  day, 
first  on  neck  and  chest; 
spreads  rapidly. 


Eruption  uniform  or  in 
large  patches  of  scarlet 
hue,  with  interspersed 
raised  spots  and  some 
vesicles ;  rash,  followed, 
after  the  seventh  day 
from  its  appearance,  by 
complete  desquama- 
tion. 

Sore  throat ;  rarely  co- 
ryza  or  bronchitis. 

Red  "  raspberry" 
tongue. 

Cerebral  symptoms  fre- 
quent and  grave. 

Temperature  very  high ; 
may  range  from  105° 
to  110° ;  no  fall  soon 
after  eruption,  nor  de- 
cided increase  of  heat 
preceding  it ;  high 
temperature  during 
height  of  eruption ; 
subsequently  gradual 
decline.  In  protracted 
cases,  a  fall  of  tempera- 
ture takes  place  on  the 


Measles. 

Period  of  incubation 
generally  from  seven 
to  fourteen  days. 

Fever,  with  moderate 
frequency  of  pulse ; 
not  relieved,  but 
rather  increased,  by 
eruption. 

Eruption  on  fourth  day, 
first  on  face ;  spreads 
gradually,  in  course 
of  about  fortj'-eight 
hours,  to  rest  of  body. 

Eruption  in  crescentic 
patches,  with  inter- 
vening portions  of 
healthy  skin  ;  lasts 
about  five  daj's ;  fol- 
lowed by  partial  and 
very  incomplete  des- 
quamation ;  scales,  as  a 
rule,  very  fine. 

Coryza  and  bronchitis 
very  constant ;  rarely 
sore  throat. 

Tongue  coated ;  may  be 
red  at  edges. 

Cerebral  symptoms 

neither  frequent  nor 
grave. 

Temperature  during  the 
fever  preceding  erup- 
tion rarely  over  from 
102°  to  103° ;  fivUs  on 
second  daj',  rises  rap- 
idly toward  breaking 
out  of  the  eruption, 
and  remains  high  dur- 
ing its  appearance  and 
spread ;  then  sinks 
speedily.  The  defer- 
vescence    that     takes 


Smallpox. 

Period  of  incubation 
generally  about  twelve 
day.s. 

Fever,  with  bounding 
pulse,  and  pain  in  the 
loins ;  great  relief 
from  occurrence  of 
eruption. 

Eruption  at  end  of  third 
or  on  fourth  day  ;  first 
on  lips  and  forehead ; 
a  preceding  red  erup- 
tion on  arms,  on  pubic 
and  inguinal  regions. 

Ei'uption  first  papular ; 
remains  so  about  a 
day ;  then  becomes 
vesicular,  then  pustu- 
lar ;  on  the  eighth  day 
of  eruption,  pustules 
maturate. 


Often  sore  throat  and  dry 
cough;  bronchitis  only 
as  a  complication. 

Tongue  coated  and  swol- 
len ;  may  become  red 
at  edges. 

Cerebral  symptoms,  es- 
pecially convulsions 
in  children,  frequent 

Temperature  during  the 
fever  preceding  erup- 
tion very  high,  often 
100° ;  then  decided 
defervescence,  taking 
place  within  thirty-six 
hours ;  subsequently 
thermometer  indica- 
ting a  temperature  of 
about  100°,  notwith- 
standing the  pi'ogress- 
ing     development    of 


FEVERS. 


901 


Table  kxhibiting  thk  Differences  between  Scarlet  Fever, 
Measles,  and  Smallpox. — Continued. 


Scarlet  Fever. 
iifth,  tenth,  and  fif- 
teenth days  of  the  dis- 
ease.* Irregular  cases 
have  ii'regular,  though 
mostly  very  high,  tem- 
peratures. 


No  secondary  fever. 


Pneumonia  rare ;  pleu- 
risy more  frequent. 

Sequelae :  Bright's  dis- 
ease ;  dropsy ;  con- 
junctivitis;  deafness; 
phthisis ;  chronic  diar- 
rhoea ;  glandular  en- 
largements ;  epilepsy. 


Measles. 
place,  generally  with- 
in from  twenty-four 
to  forty-eight  hours, 
is  both  rapid  and  com- 
plete. A  protracted 
defervescence  indicates 
a  severe  case ;  a  high 
temperature  after  the 
rash  has  faded  is  due 
to  a  complication. 

No  secondary  fever ; 
although  sometimes 
a  slight  increase  of 
fever  just  before  erup- 
tion leaves. 

Pneumonia  a  very  fre- 
quent complication. 

Sequelae :  chronic  bron- 
chitis ;  phthisis ;  con- 
junctivitis. 


Smallpox. 
the  pimples  into  pus- 
tules. Decided  rise  of 
temperature  during 
secondary  fever,  and 
then  gradual  and  pro- 
tracted defervescence ; 
a  slight  rise  during 
desiccation. 


Always  secondary  fever. 


Pneumonia  not  a  very 
frequent  complication. 

SequeliS :  chronic  diar- 
rhoea ;  glandular  en- 
largements ;  various 
diseases  of  the  eyeball 
and  eyelids. 


The  contagion  of  smallpox  does  not  always  manifest  itself  by 
an  attack  of  variola.  Sometimes  it  is  modified  by  happening  in 
a  person  who  is  partially  protected  by  vaccination.  This  varioloid 
disease  is  mild  and  very  rarely  fatal ;  it  protects  against  smallpox. 
It  is  distinguished  from  variola  by  the  pustules  passing  more 
quickly  through  all  their  stages,  and,  above  all,  by  an  absence  of 
secondary  fever.  Soon  after  the  eruption — within  thirty-six  hours 
— the  thermometer  shows  freedom  from  fever,  and,  unless  serious 
complications  happen,  the  temperature  remains  nearly  normal. 
The  suppuration  is  far  less  deep  ;  and  the  resulting  cicatrices  are 
often  scarcely  discernible. 

Varicella. — A  specific  disorder  similar  to  but  not  identical  with 
variola  or  varioloid  is  chicken-pox,  or  varicella.  It  differs,  as 
regards  its  symptoms,  from  smallpox  in  the  leniency  of  the  intro- 


*  Einger. 


002 


MEDICAL    DIAGNOSIS. 


Fig.  70. 


duotoiy  fever;   in  the  eruption  beginning  generally  first  on  the 
trunk,  ocx^urring  often   on   the  second   day,  thougli   it  may  not 

show  itself  until  the  end  of  the 
third,  and  continuing  to  appear 
and  disa})pcar  in  crops,  the  mass 
of  the  eruption,  however,  having 
become  evident  within  twenty-four 
hours ;  in  the  vesicles  being  sur- 
rounded by  little  or  no  inflamma- 
tory redness ;  in  their  remaining 
vesicles  and  not  becoming  pus- 
tules ;  in  their  -attaining  their 
height  on  the  third  or  fourth  day 
of  the  eruption,  and  then  burst- 
ing and  shrivelling  without  i)re- 
senting  depressions  at  their  apices, 
and  in  the  crust  which  falls  off 
a1>out  five  days  subsequently  being 
followed  by  a  smooth,  shining, 
round,  and  irregular  pit.  Then 
the  eruption  is  rarely  prominent 
on  the  face ;  and  the  disease  does 
not  protect,  as  mild  forms  of 
smallpox  do,  from  a  subsequent 
attack  of  variola.  Sometimes  the 
vesicles  may  be  found,  as  are  the 
pustules  of  smallpox,  on  the  roof 
of  the  mouth  and  at  the  back 
of  the  throat.  But,  notwithstand- 
ing they  may  be  everywhere  very 
plentiful,  the  disorder  is  not  a  grave  one.  Still,  I  have  known 
it  in  one  case  to  terminate  fatally. 

Dengue. — This  is  an  arthritic  fever  with  a  cutaneous  erup- 
tion. It  has  been  prevalent  in  the  form  of  epidemics  chiefly  in 
India,  and  in  the  West  Indies,  as  well  as  in  Virginia,  South  Caro- 
lina, Texas,  and  other  of  the  Southern  States. 

It  usually  begins  with  pain,  stiffness,  and  swelling  of  some  of 
the  smaller  joints,  or  with  severe  muscular  pains,  aching  in  the 
back,  and  stiffness  of  the  muscles  of  the  neck.     Fever  follows, 


Temperature-record  in  varioloid  ending  in 
recovery ;  tlie  absence  of  secondary  fever  is 
clearly  seen.     (After  Wunderlich.) 


FEVERS.  DO.'J 

with  suffusion  of  the  eyes,  violent  headache,  hurried  breathing, 
and  coated  tongue ;  but,  as  a  rule,  without  nausea  and  vomiting. 
The  temperature  usually  attains  its  height  within  the  first  twenty- 
four  hours,  and  then  shows  during  defervescence  marked  remis- 
sions and  exacerbations.  On  the  third  day  the  fever  ceases 
altogether,  or  subsides  markedly,  though  the  muscular  and  ar- 
thritic pains  do  not  pass  off  entirely.  The  febrile  parox}'sm  may 
last  somewhat  longer,  indeed,  five  to  seven  days,  or  only  six  to 
twelve  hours.  In  any  case  it  is  apt  to  be  succeeded  by  an  interval 
of  two  to  four  days  free  from  absolute  suffering,  though  not  from 
great  debility.  Then  the  pain  returns,  and  with  it  a  moderate 
fever ;  nausea  and  vomiting  and  a  thickly-coated  tongue,  too,  are 
noticed.  This  new  phase  of  tlie  complaint  is  generally  relieved 
by  the  appearance  of  an  eruption,  which  may  be  accompanied  by 
a  slight  rise  in  temperature.  The  eruption  shows  itself  on  the 
fifth,  sixth,  or  seventh  day  of  the  malady,  and,  therefore,  very 
much  later  than  the  rash  of  scarlatina,  which  it  resembles  in  hue 
and  aspect.  But  not  invariably  ;  for  it  may  occur  in  patches  and 
be  j)apular,  or  even  vesicular  or  like  urticaria.  The  eruption  is 
attended  with  a  sense  of  burning  and  of  itching,  and  disappears 
after  two  or  three  days'  duration,  with  more  or  less  decided  des- 
quamation. It  is  much  more  pronounced  than  the  slight  and 
inconstant  erythematous  rash  of  the  period  of  invasion,  which 
disappears  without  desquamation  with  the  febrile  stage. 

With  the  occurreuce  of  desquamation  following  the  marked 
rash  of  the  third  period  of  the  disease  convalescence  sets  in, 
marked  by  considerable  muscular  weakness  and  general  depres- 
sion, and  frequently  with  the  rheumatic  stiffness  or  soreness  per- 
sisting for  some  time.  Swellings  of  the  lymphatic  glands  of 
the  neck,  axilla,  and  groin  occur  in  many  instances,  and  may 
continue  during  convalescence,  which  in  any  case  is  apt  to  be 
prolonged,  and  may  be  interrupted  by  a  relapse. 

The  cause  of  this  singular  malady — the  breakbone  fever  of 
parts  of  our  country — is  unknown.  McLoughlin  *  has  invaria- 
bly fouiid  in  the  blood  micrococci  in  great  numbers,  about  one- 
twentieth  to  one-thirtieth  the  diameter  of  the  red  corpuscles,  of 
spherical  shape,  and  red  or  purplish  in  color. 

*  Journ.  Amer.  Med.  Assoc,  June  19,  1886. 


904  MEDICAL   DIAGNOSIS. 

Dengue  is  generally  a  harmless  disorder,  epidemic,  and  con- 
tagious. Isolated  cases  are  ditiicult  of  diagnosis,  but  when  the 
disease  largely  prevails  its  recognition  is  easy.  It  differs  from 
rhcwnatism  or  gout  by  the  significant  features  of  the  fever  and 
the  eruption ;  from  scarlet  feccr  by  the  different  character  and 
want  of  coutinuousness  of  the  fever,  and  the  arthritic  symptoms; 
from  influenza  by  these  and  the  eruption.  The  remission  may 
cause  the  disease  to  be  mistaken  for  a  malarial  fever ;  but  the 
irregularity  of  the  fever  in  dengue,  the  joint  and  muscle  pains, 
and  the  absence  of  hepatic  and  splenic  enlargement  are  very 
unlike.  Dengue  has  a  closer  resemblance  to  yellow  fecer,  and  the 
difficulty  of  distinction  becomes  the  greater  because  epidemics  of 
both  may  be  present  side  by  side.  But  the  single  paroxysm,  the 
tongue  with  red  edges,  the  yellow  skin,  the  frequent  vomiting,  the 
hemorrhage,  the  grave  nervous  symptoms,  and  the  albuminous 
urine  are  not  met  with  in  dengue. 

Erysipelas. — This  disease,  as  the  physician  sees  it,  is  mostly 
confined  to  the  head  and  face.  It  may  or  may  not  be  found  to 
have  been  preceded  by  a  scratch  or  an  abrasion.  It  is  an  eruptive 
fever  beginning  with  a  chill.  Soon  a  portion  of  the  face  is  no- 
ticed to  be  red  and  hot.  The  redness  spreads,  a  clearly-defined 
edge  marking  its  onward  march ;  and  generally  it  does  not  stop 
until  it  has  occupied  the  whole  of  the  face  and  a  considerable 
portion  of  the  scalp.  The  features  are  then  so  tumefied  as  to  be 
hardly  recognizable.  The  patient  is  very  restless,  has  high  fever, 
and  not  unfrequently  enlargement  of  the  glands  at  the  angle  of 
the  jaw,  and  sore  throat.  By  the  seventh  or  eighth  day  the  dis- 
ease is  over,  and  large  patches  of  cuticle  fall  from  the  no  longer 
swollen  and  disfigured  countenance. 

This  is  simple  erysipelas ;  but  the  affection  may  extend — as  is, 
in  truth,  its  tendency — from  the  true  skin  to  the  subcutaneous 
areolar  tissue,  and  give  rise  there  to  collections  of  pus,  which 
reveal  their  presence  by  chills  and  an  obscure  sense  of  fluctuation, 
and  keep  up  an  ii-ritative  fever  until  they  are  discharged.  Irre- 
spective of  tiiis,  the  tumefaction,  while  the  complaint  is  at  its 
height,  is  much  greater  in  this  phlegmonous  variety  of  the  malady, 
and  there  is  more  constitutional  disturbance ;  but,  on  the  other 
hand,  there  is  not  so  much  local  irritation,  for  the  morbid  action 
travels  less  rapidly,  and  often  remains  more  circumscribed.     In 


FEVERS.  905 

some  cases  the  inflammation  extends  to  the  brain,  and  instead  of 
wandering  at  night,  always  a  very  common  symptom,  we  have 
violent  delirium,  soon  succeeded  by  coma  and  rapid  sinking.  In 
other  cases,  again,  and  they  are  by  far  the  most  frequent,  we  may 
find  these  active  cerebral  symptoms  and  yet  not  be  able  to  detect, 
after  death,  signs  of  inflammation  of  the  brain  or  its  membranes. 
No^v  and  then  the  disorder  passes  to  the  throat,  reaches  the  larynx 
and  bronchial  tubes,  and  places  life  in  imminent  peril  from  oedema 
of  the  glottis,  or  from  a  hazardous  form  of  capillary  bronchitis. 
In  some  instances  a  highly-asthenic  state  becomes  developed,  and 
the  patient  dies  exhausted. 

Internal  lesions  happen  not  unfrequently  in  erysipelas.  I  have 
found  the  urine  albuminous  in  the  great  majority  of  instances.* 
Heart-murmurs  are  not  unusual,  and  are  said  to  depend  upon 
endocarditis,  which  is  doubtful.  Friedreichf  speaks  of  swelling 
of  the  spleen  being  of  common  occurrence  both  in  erysipelas  and 
in  diphtheria. 

The  diagnosis  of  erysipelas  is  not  beset  with  difficulties.  Ery- 
thema resembles  it  very  closely ;  but  there  is  this  manifest  differ- 
ence :  in  erythema  there  is  scarcely  any  swelling,  not  much  ten- 
dency to  spread,  and  almost  no  constitutional  disturbance.  The 
ordinary  exanthematous  fevers  may,  at  an  early  stage,  be  mistaken 
for  erysipelas.  But  all  of  them,  even  scarlatina,  have  a  longer 
period  of  febrile  invasion  ;  in  all,  too,  although  the  eruption  takes 
its  origin  at  one  spot,  and  generally  on  the  face,  it  is  not  lim- 
ited there.  The  thickly-clustered  blotches  of  beginning  confluent 
smallpox  and  the  swelling  attending  them  give  at  times  to  the  face 
the  look  of  erysipelas.  But  here,  also,  evidences  can  be  found  of 
a  rash  about  to  appear  all  over  the  body  ;  and  should  doubt  still 
exist,  it  is  soon  dispelled  by  the  progress  of  the  eruption.  Some- 
times vesicles  and  even  irregular  pustules  form  in  erysipelas,  and 
occasion  some  misgivings  as  to  whether  the  maladv  be  not  a 
chronic  disease  of  the  skin,  such  as  eczema,  pemphigus,  or  impe- 
tigo ;  but  these  affections  lack  the  constitutional  symptoms  and  the 
history  of  a  recent  acute  disease,  and  in  reality  the  likeness  is  not  a 
very  striking  one,  if  the  inflamed  surface  be  carefully  examined. 

*  On  the  Internal  Complications  of  Acute  Eiysipelas,  Amer.  Journ.  Med. 
Sci.,  Oct.  1877. 

f  Klinische  Vortriige,  No.  75,  1874. 


90G  MEDICAL   DIAGNOSIS. 

Tho  closest  similarity  is  to  herpes  zoster  of  the  forehead  and  face. 
But  the  eruption  in  this  does  not  ]iass  tlie  middle  line.* 

Erysipelas  may  break  out  in  one  pai't  of  the  body  after  an- 
other, and  the  disease  be  thus  kept  uj>  for  a  long  period.  This 
erysipelas  migrans  runs  its  course  more  rapidly  and  more  com- 
pletely in  one  part  than  in  another,  and  in  accordance  with  a 
general  law  which  it  obeys.f 

Erysipelas  may  be  confounded  with  mumps.  This  does  not 
seem  at  first  sight  likely;  but  I  have  known  the  error  to  be  com- 
mitted. It  was  mainly  caused  by  too  much  stress  being  laid  on 
the  redness  which  is  frequently  found  beneath  one  or  both  ears  in 
parotitis,  but  Avhich,  unlike  erysipelas,  is  attended  with  much  pain 
on  moving  the  jaw,  and  with  decided  glandular  tumefaction.  The 
redness,  moreover,  shows  no  tendency  to  spread,  and  rarely  con- 
tinues for  the  four  or  five  days  during  which  mumps  lasts.  In 
very  young  children,  however,  there  may  be  some  difficulty  in 
diagnosis.  I  have  seen  the  glands  at  the  angle  of  the  jaw  much 
swollen  for  one  or  two  days  prior  to  the  slight  discoloration  over 
them  taking  on  a  deeper  blush,  and  then  spreading  rapidly  as 
marked  erysipelas  over  the  whole  face  and  part  of  the  scalp,  reach- 
ing the  other  jaw,  where  subsequently  the  glands  began  to  swell. 
In  such  cases  great  weight  must  be  attached  to  the  history  of 
the  case,  to  determine  which  disorder  was  primary,  and  whether 
the  glandular  complaint  was  or  was  not  the  complication. 

A  fever  with  a  distinct  pharyngitis  as  a  local  manifestation,  the 
so-called  pharyngeal  fever,  is  probably  an  epidemic  erysipelatous 
fever  of  light  type.  It  has  been  particularly  described  by  Austin 
Flint,  Hochester,!  and  Harvey  E.  Brown. §  The  fever  lasts  from 
three  to  six  days,  and,  besides  the  marked  pharyngitis,  is  ordi- 
narily attended  with  swelling  of  the  lymphatic  glands  of  the  neck, 
accompanied  by  pain.  The  disease  shows  a  certain  proportion  of 
cases  with  erysipelas  of  the  face,  and  is  thought  to  be  a  mild  form 
of  the  fever,  known  popularly  as  the  "  black  tongue,"  which  pre- 
vailed in  this  country  from  1841  to  1846,  and  in  about  one-sixth 
of  the  cases  of  which  erysipelas  happened. || 

*  Fagge,  Practice  of  Medicine,  vol.  i.  p.  271. 

f  Traced  by  Pfliiger  in  70  cases;  quoted  in  Schmidt's  .Jalirb.,  No.  7,  1873. 

X  Buffiilo  Medical  Journal,  1857. 

§  Flint'*  Principles  and  Practice  of  Medicine.  ||  Ibid. 


CHAPTER   XIII. 

DISEASES   OF   THE   SKIN. 

To  facilitate  the  discrimination  of  diseases  of  the  skin,  they 
have  been  grouped  into  classes.  These  have  been  arranged  by 
some  in  accordance  with  the  obvious  characters  of  the  eruption, 
by  others  in  accordance  with  its  presupposed  cause  and  attending 
structural  alteration.  An  extensively-used  system  of  classification 
takes  for  its  basis  the  anatomical  seat  and  arrangement  of  the  cuta- 
neous malady  :  it  is  that  of  Hebra.  As  developed  by  him,  it  is, 
however,  not  a  purely  anatomical,  but  a  mixed  system,  resting 
largely  on  a  pathological  basis.  Similar  is  the  classification  of  the 
American  Dermatological  Association,  now  much  followed.  All 
diseases  of  the  skin  are  arranged  in  eight  classes :  Disorders  of 
the  Glands,  sweat  and  sebaceous;  Inflammations;  Hemorrhages; 
Hypertrophies,  of  pigment,  epidermal,  and  papillary  layers,  and 
of  connective  tissue  ;  Atrophies,  of  pigment,  hair,  nail,  and  cutis ; 
New  Growths,  of  connective  tissue,  vessels,  and  granulation-tis- 
sue ;  Neuroses ;  and  Parasitic  Affections,  vegetable  and  animal. 
Whatever  classification  we  adopt,  Avhen  a  disease  of  the  skin  is 
presented  for  examination  we  generally  first  endeavor  to  ascertain 
the  group  it  belongs  to ;  for  instance,  is  it  macular,  papular,  vesic- 
ular, or  pustular?  Having  determined  this,  we  next  fix  which 
one  of  the  group  it  is ;  and  then  take  note  of  its  precise  seat  and 
its  pathological  causation.  When  this  has  been  accomplished,  we 
inquire  into  the  history  of  the  affection  and  its  duration,  whether 
acute  or  chronic ;  take  into  account  the  presence  or  absence  of 
fever,  and  the  general  condition  of  the  patient ;  search  for  the 
evidences  of  a  cachexia  or  of  some  visceral  disturbance, — a  study 
the  importance  of  which  is  as  great  as  that  of  the  recognition  of 
the  cutaneous  malady;  and  trace,  as  fiir  as  possible,  the  cause  of 
the  disorder.  Having  done  all  this,  we  have  a  groundwork  upon 
which  to  institute  suitable  treatment. 

907 


908 


MEDICAL    DIAGNOSIS. 


Here  is  a  table  in  ^Yhicll  cutaneous  affections,  omitting  some 
of  the  less  important  ones,  are  grouped  according  to  their  most 
obvious  featiu-es,  as  well  as  according  to  their  pathological  bearings  : 


Diseases  of  the  Skin. 

Erythematous  Diseases...  -{ 

I 
Papular  Diseases -j 

Vesicular  Diseases / 


Inflammatory,  j 


Bullous  Diseases. 


Pustular  Diseases 


Squamous  Diseases. 


MaCULJE  ;     PiGMENTARY   ChAKGES. 


r 

New  Growths j 

I 

\ 
Hypertrophies  of  Special  Textures \ 


Atrophies. 


Parasitic  Diseases., 


Erythonia. 

Koseola. 

Urticaria. 

Lichen. 
Prurigo. 
Eczema. 
Herpes. 

Pemphigus. 

Hydroa. 

Acne. 

Sycosis  non-parasitica. 

Impetigo. 

Ecthyma. 

Kupia. 

Psoriasis. 

Pityriasis. 

Ichthyosis. 

Melasma. 

Ephelides. 

Vitiligo. 

Chloasmata. 

Na2vi. 

Cancer. 

Lupus. 

Lepros}',  etc. 

Elephantiasis  Arabum. 

Scleroderma. 

Keloid. 

Warts,  Corns,  etc. 

As  of  the  Hair;  the  Nails. 

Senile  Atrophy. 

Scabies. 

Phtheiriasis. 

Favus. 

Tinea    sycosis,   or    Men- 

tagra. 
Tinea  circinata. 
Tinea  tonsurans. 
Tinea  decalvans. 
Tinea  versicolor,  etc. 


DISEASES   OF   THE   SKIN.  909 

Diseases  of  the  Skin. — Continued. 


Altered  Gland-Secretion.. 


of  Sebaceous  Glands.  |  ^<'^>"'■'■^^^' 


of  Sweat-Glunds. 


Molluscurn. 

r  Ilypcridrosis. 

Anidrosis. 
L  Sudamina,  etc. 
r  Hypera3sthesia. 

Nervous  Affections -j   A"'«sthesia. 

Pruritus. 
[  Neuroma. 

_  „  .  r  Syphiloderrnata. 

Constitutional  Skin  Affections i  a  %■  -,   i 

I  Scroiulodermata,  etc. 

Most  diseases  of  the  skin  are  again  subdivided  into  several 
varieties,  based,  for  the  most  part,  on  their  duration,  situation, 
form,  feel,  and  color.  Thus,  we  have  constantly  recurring  the 
terms  fugax,  inveterata,  capitis,  facialis^  palmaris ;  guttata,  when 
like  a  drop  on  the  skin;  nummularis,  when  like  a  coin;  larvalis, 
like  a  mask,  etc.;  the  qualifying  words  Iseve,  induratum ;  and 
the  adjectives  of  color,  nigrum,  rubrum,  versicolor.  But  these 
divisions  are  all  of  secondary  importance ;  and  in  this  outline  not 
much  regard  will  be  paid  to  them.  Premising  this  statement, 
let  us  briefly  examine  the  characteristics  of  the  various  cutaneous 
aflFections  of  more  common  form,  beginning  with  those  of  inflam- 
matory origin. 

Erythematous  Diseases. — There  are  only  three  affections 
which,  strictly  speaking,  come  under  this  division  of  cutaneous 
complaints :  erythema,  roseola,  and  urticaria.  In  all  of  these  the 
skin  is  more  or  less  red,  and  its  surface  unbroken ;  the  hypersemia 
aflects  chiefly  the  papillary  layer. 

Erythema. — This  is  characterized  by  a  uniform  and  continuous 
redness  of  the  skin,  occurring  in  irregular  patches  of  some  size, 
attended  with  some  burning,  and  with  but  slight  swelling,  if  with 
any,  and  disappearing  without  desquamation  or  mark  or  scar. 
The  eruption  is  chiefly  found  on  the  back  of  the  hands,  the 
forearms,  the  legs,  and  the  face  and  neck  ;  rarely  on  the  trunk. 
There  is  little  or  no  itching.  The  affection  may  be  due  to  the 
action  of  heat  or  cold,  or  of  irritants ;  or  it  may  be  connected 
with  some  visceral  abdominal  disorder.  It  is  usually  acute. 
There  is  only  one  variety  apt  to  be  combined  with  decided  con- 


910  MEDICAL    DIAGNOSIS. 

stitiitlonal  or  febrile  symptom.s, — the  hard,  painful,  reddish  pro- 
tuberanees  most  commonly  seen  on  the  legs,  and  constituting  the 
so-called  "erythema  nodosum."  Tliis  form  of  the  complaint,  in 
which  there  is  a  serous  effusion  into  or  under  the  skin,  is  chiefly 
observed  in  those  of  rheumatic  diathesis,  and,  unlike  the  simple 
erythema  and  the  erythema  intertrigo,  which  are  looked  upon  as 
mere  hypersemias,  is  classed  with  the  exudations  or  inflammations. 

There  is  a  dcsquamafivc  form  of  erythema  resembling  scarlet 
fever,  attended  with  fever  of  a  few  days'  duration,  with  epistaxis, 
and  showing  an  extraoicliuary  tendency  to  relapses.  The  erup- 
tion is  uniform  and  intensely  red,  and  there  is  no  sore  throat,  or 
there  is  mere  redness  of  the  fauces. 

A  chronic  form  of  erythema  results  from  pressure,  or  the  rub- 
bing together  of  folds  of  skin,  the  erythema  intertrigo ;  a  slight 
discharge  may  coat  the  rubbed  surface. 

Roseola. — The  affection  consists  in  circumscribed  spots  of  a 
rose-red  color  and  of  a  more  or  less  circular  form.  The  spots  are 
smaller  than  those  of  erythema.  There  is  slight  fever,  and  at 
times  redness  of  the  fauces.  The  affection  often  exists  in  con- 
nection with  a  derangement  of  the  stomach,  or  with  rheumatism, 
is  frequent  in  summer  and  in  autumn,  is  generally  acute,  and  bears 
a  certain  resemblance  to  scarlatina  and  to  measles ;  but  it  is  not 
contagious,  its  constitutional  symptoms  are  much  milder,  the  rash 
is  rosy,  not  crescentic,  nor  present  over  the  wliole  l)ody,  and  we 
find  neither  the  marked  sore  throat  of  scarlet  fever  nor  the  catarrh 
of  measles. 

Urticaria, — Nettle-rash  gives  rise  to  prominent  and  perfectly 
smooth  patches,  the  color  of  which  is  either  redder  or  whiter  than 
the  surrounding  skin,  or  the  white  wheals  are  surrounded  by  a 
red  border.  The  wheals  are  generally  small,  but  they  may  be  of 
the  size  of  the  palm.  The  eruption  is  fugitive  and  capricious,  is 
attended  with  more  itching,  burning,  and  tingling  than  the  other 
exanthemata,  and  is  much  more  evanescent,  generally  disappear- 
ing in  two  days  at  furthest.  It  may,  however,  exist  in  a  chronic 
form,  the  wheals  coming  out  in  constant  succession. 

The  cause  of  urticaria  is  irritation  of  the  gastro-intestinal,  pul- 
monary, or  urinary  mucous  membrane.  Certain  kinds  of  fish, 
especially  shell-fish,  are  iDarticularly  prone  to  produce  it ;  so  may 
mushrooms  and  strawberries.     At  times  it  is  due  to  menstrual 


DISEASES   OF   THE  SKIN.  Oil 

disorders,  or  to  sudden  mental  emotion,  (H'  to  the  excessive  use 
of  mineral  waters,  or  to  antipyrin.  It  may  be  secondary  to  the 
itch  or  to  phtheiriasis.  It  occurs  in  cere})ro-spinal  fever,  and  is 
common  in  dengue,  especially  in  children.* 

Urticaria  is  thought  generally  to  be  an  exudative  disease  of  the 
skin  ;  yet  it  seems  most  probable  that  it  is  a  reflex  phenomenon, 
caused  chiefly  by  reflected  irritation  to  the  cutaneous  vaso-niotor 
nerves.  Urticaria  resembles  erythema  nodosum  ;  but  there  is  no 
itching  in  the  latter  affection,  it  is  chiefly  found  in  the  lo^ver  limbs, 
and  the  swellings  change  like  bruises. 

Papular  Diseases. — A  papule,  or  pimple,  is  a  small  elevation 
of  the  cuticle  with  an  inflamed  base ;  it  does  not  contain  fluid, 
and  usually  terminates  in  desquamation.  It  results  from  a  small 
amount  of  lymph  or  a  newly-formed  growth  in  the  derm  itself. 

Lichen. — This  furnishes  the  best-marked  example  of  a  papular 
eruption.  It  consists  of  minute  conical  papulce,  generally  of  red- 
dish color,  and  occurring  in  clusters.  It  is  most  frequently  en- 
countered in  the  summer  months  and  in  adults,  and  often  in 
persons  who  are  in  good  health  but  who  have  been  exposed  to 
much  fatigue  or  anxiety.  Sometimes  it  is  evidently  connected  with 
disordered  digestion.  It  is  commonly  chronic.  There  is  often  a 
mixture  of  papulas  with  an  eczematous  eruption.  Prickly  heat, 
or  lichen  tropicus,  frequently  exhibits  also  sudamiua,  and  is  called 
by  some  "  miliaria  papulosa." 

In  the  lichen  ruber  of  Hebra  the  red  papules  are  of  the  size  of 
the  head  of  a  pin ;  they  spread  by  peripheral  growth,  are  flat, 
irregular,  and  have  a  glazed  look  and  v'ery  slight  scales ;  there 
is  considerable  itching.  The  disease,  which  is  an  inflammatory 
one,  is  chronic ;  its  common  site  is  on  the  forearm.  It  resembles 
psoriasis,  but  at  the  edge  of  the  patch  are  the  characteristic 
papules.  Poor  nutrition  and  nervous  exhaustion  are  its  main 
causes. 

In  the  lichen  scrofulosonim  the  eruption  consists  of  little  pale 
papules,  which  are  chiefly  found  on  the  trunk.  There  is  no 
itching ;  but  we  find  marked  signs  of  scrofula. 

Prurigo. — This  is  characterized  by  a  papular  affection  of  the 
skin  attended  with  excessive  itchins;.     It  is  a  verv  rare  disease  in 


*  J.  C.  Wilson,  Treatise  on  the  Continued  Fevers,  1881. 


912  MEDICAL   DIAGNOSIS. 

tliis  country/"  The  piinplos  are  generally  torn  by  the  finger- 
nails, and  are  surmounted  by  black  scabs.  They  are  not  red,  as 
those  of  iichen  usually  are,  and  are,  as  a  rule,  largxM-,  and  accom- 
panied by  much  more  pruritus  and  by  thickening  of  the  skin. 
The  affection,  which  is  uncommon,  may  or  may  not  be  attended 
with  constitutional  symptoms.  It  is  very  obstinate,  especially 
when  happening  in  old  persons.  It  generally  aifects  the  legs,  the 
arms,  and  the  trunk,  rarely  the  face  and  the  neck,  never  the  palms 
and  the  soles.  The  skin  of  the  anterior  and  outer  part  of  the  leg 
is  most  changed ;  that  over  the  flexors  in  the  forearm  is  always 
healthy.  The  distressing  disorder  may  be  purely  local,  occurring 
around  the  anus,  or  on  the  scrotum  and  the  root  of  the  penis,  or 
on  the  pudenda.  Some  of  these  cases,  however,  though  called 
prurigo,  present  no  papuhe,  and  the  disorder  is  due  to  perverted 
sensibility  of  tlie  cutaneous  nerves  alone,  and  is  really  a  pruritus. 
Prurigo  is  often  attended  with  eczema. 

A  good  many  supposed  instances  of  the  malady  are  not  really 
prurigo,  but  phtheiriasis,  due  to  the  irritation  of  body-lice,  that 
produce  papules,  whose  apices  are  scratched  off  and  show  little 
points  of  dried  blood.  True  prurigo  is  frequently  found  to  be 
connected  with  deterioration  of  the  health,  and  is  chiefly  met  with 
among  the  poor  and  the  neglected.  It  may  last  a  lifetime,  begin- 
ning in  childhood.  Its  local  forms  are  associated  wath  irritation 
of  the  bladder,  the  rectum,  or  the  uterus. 

Vesicular  Diseases. — These  are  characterized  by  an  effusion 
of  a  clear  or  a  sero-purulent  fluid  beneath  the  epidermis,  which  is 
generally  raised  in  small  elevations.  To  the  class  of  vesicular 
diseases  belong  especially  eczema  and  herpes. 

Eczema. — The  malady  consists  of  minute  vesicles  collected 
together  in  irregular  patches.  The  vesicles  are  often  confluent, 
and  it  then  appears  as  if  the  whole  surface  were  secreting  fluid. 
This  may  harden,  from  exposure  to  the  air,  in  scabs  of  various 
thickness  and  color.  The  skin  itself  is  often  of  a  vividly  red 
hue ;  indeed,  it  is  inflamed,  and  a  new  cell-growth  takes  place 
both  in  the  rete  mucosum  and  in  the  papillary  layer  of  the  derm. 
It  is  there  that  the  effusion  of  serum  begins.  In  chronic  cases 
the  inflammatory  infiltration  extends  deeper  into  the  skin. 

*  Only  34  cases  in  123,746  of  skin-disease :  Van  Harlingen  on  Skin-Diseases. 


DISEASES   OF   THE   SKIN.  013 

Eczema  is  the  most  common  of  all  the  cutaneous  maladies ;  Ijut 
it  is  not  contagious.  It  may  affect  the  whole  body,  yet  is  ordi- 
narily limited  to  some  portion  of  it.  It  is  acute  or  chronic.  The 
former  is  generally  seen  as  the  effect  of  local  irritants,  and  may  be 
met  with  in  young  and  healthy  persons.  Chronic  eczema  is  more 
usual,  is  often  the  consequence  of  constitutional  disturbance,  and 
is  frequently  found  to  be  associated  with  some  disorder  of  the 
digestive  system.  It  has  as  a  frequent  seat  the  flexor  surfaces 
of  the  limbs.  Dentition  and  unhealthy  milk  are  common  sources 
of  the  affection  in  very  young  children.  In  them  the  disease  is 
extremely  apt  to  attack  the  scalp  and  face,  forming  the  complaint 
often  described  as  "  crusta  lactea ;"  or,  if  the  secretion  be  partly 
purulent,  or  early  become  so,  and  dry  into  large,  dark  scabs,  the 
malady  is  designated  as  eczema  impetiginodes.  This  is  most  often 
met  with  in  scrofulous  subjects.  There  is  less  heat  and  itching 
than  in  other  forms  of  eczema. 

In  some  of  the  forms  of  eczema,  especially  in  its  chronic  varie- 
ties, the  vesicles  supposed  to  characterize  the  disorder  can  often 
not  be  found.  This  and  other  reasons  have  caused  several  derma- 
tologists, especially  Hebra*  and  Anderson,f  to  deny  that  eczema 
need  be  vesicular  at  all.  Infiltration  of  the  skin,  exudation  on 
its  surface,  the  formation  of  crusts,  and  itching,  are  held  to  be  its 
distinctive  signs  while  the  eruption  is  at  its  height ;  but  the  erup- 
tion may  consist  of  clusters  of  papules,  vesicles,  or  pustules,  or 
there  may  not  be  a  vestige  of  any  of  these,  the  skin  being  thick- 
ened, red,  and  smooth  and  secreting  a  sticky  discharge,  or  covered 
with  green  or  gummy  crusts,  or  fissured  with  deep  cracks ;  yet 
there  are  no  ulcerations.  Not  unfrequently  the  disorder  begins 
as  an  erythema.  A  scaly  form  of  eczema,  eczema  squamosum,  is 
apt  to  be  confined  to  the  hands  and  feet.  In  all  the  forms  of 
eczema,  as  Hebra  insists  upon,  there  is  severe  itching.  This 
itching  is  especially  violent  in  the  form  with  the  deep-red  and 
weeping  surface,  named  eczema  ruhrum.  It  is  in  this  variety  that 
we  find  the  signs  of  local  inflammation  very  marked,  and  we 
often  see  it  in  gouty  or  in  dyspeptic  subjects.  It  has  a  predi- 
lection for  the  flexures  of  the  joints. 


*  Hautkrankheiten  ;  or  translation  by  Sydenham  Society, 
t  A  Practical  Treatise  on  Eczema,  London,  1863. 
58 


914  MEDICAL   DIAGNOSIS. 

Eczema,  particularly  ^vlien  it  affects  the  scalp  and  face,  must 
not  be  confounded  with  the  morbid  secretion  from  the  sebaceous 
follicles  giving  rise  to  soft  crusts.  Scborrhcea  by  preference 
attacks  the  parts  mentioned  ;  but  its  crusts,  as  Hardy  has  shown, 
are  unlike  those  of  eczema  in  the  readiness  with  which  they 
are  detached,  and  are  susceptible  of  being  moulded  between  the 
fingers.  The  surface  beneath  the  crusts,  too,  is  dissimilar.  It 
has  an  oily,  glistening  look  ;  there  is  no  discharge. 

Eczema  may  be  confounded  with  jyityriasis  ruhrd.  But  this 
speedily  involves  the  whole  surface  of  the  body,  and  is  not  accom- 
panied by  discharge ;  and  there  are  large,  thin  epidermic  scales. 

Herpes. — Like  eczema,  herpes  is  classed  as  a  vesicular  affection, 
although  it  differs  from  the  obviously  vesicular  form  of  eczema 
by  the  larger  size  of  the  vesicles.  These  are  generally  of  a  glob- 
ular form,  and  are  symmetrically  arranged  in  clusters  upon  an 
inflamed  patch  of  skin.  Each  vesicle  is  distinct,  and  remains  so 
throughout  its  course.  It  lasts  about  eight  to  twelve  days,  and 
often  terminates  by  the  formation  of  a  thin  incrustation.  The 
eruption  is  attended  with  burning,  and  in  the  acute  variety  with 
some  fever. 

Herpes  has  seldom  a  longer  duration  than  three  weeks ;  though 
it  may  be  a  chronic  disease.  It  happens  usually  in  persons  of 
delicate  skin  ;  is  generally  very  local,  having  its  seat  on  the  lips, 
eyelids,  prepuce,  or  pudenda  ;  and  is  very  often  associated  with 
an  internal  disease,  especially  with  irritation  of  some  portion  of 
the  gastro-pulmonary  mucous  membrane.  Herpes  labialis  mostly 
appears  at  the  decline  or  termination  of  fevers;  sometimes  at  the 
height  of  acute  maladies,  as  in  pneumonia.  The  most  distressing 
form  of  herpes  is  that  extending  around  one-half  of  the  trunk, — 
herpes  zoster,  an  acute  disorder,  which  may  show  itself  over  the 
course  of  any  of  the  superficial  nerves,  and  is  attended  by  nerve- 
pain.  Indeed,  herj^etic  or  bullous  eruptions  often  happen  over 
the  course  of  tlie  nerves,  and  a  nerve-lesion  the  result  of  dis- 
ease or  of  an  injury  will  produce  them  over  tlic  disordered 
nerve ;  the  vesicles  are  seated  upon  a  highly-inflamed  base.  In 
herpes  zoster  around  the  chest,  the  severe  pain  preceding  the 
eruption  is  often  mistaken  for  pleurivSy. 

Herpes  and  eczema  may  both  be  confounded  with  scabies,  which, 
like  them,  occasions  a  vesicular  eruption  which  is  apt  to  be  found 


DISEASES   OF   THE   SKIN.  015 

on  the  inner  surface  of  the  limbs  and  floxui-os  of  the  joints.  'Jlie 
distinction  consists  in  the  more  severe  itching;  in  th(!  small  con- 
ical vesicles,  torn,  as  they  so  usually  arc,  by  scratching  ;  and  in  the 
presence  of  the  acarus,  which  may  be  removed  from  its  burrow 
with  the  point  of  a  needle  or  of  any  sharp  instrument. 

Bullous  Diseases. — Bullas  differ  from  vesicles  only  in  their 
size.  The  typical  bullous  disease  is  j^emphigus.  This  affection  is 
not  often  met  with  ;  it  is  more  common  in  children  than  in  adults. 
It  appears  in  very  large  vesi(iles  or  bullse,  surrounded  by  a  slight 
zone  of  erythematous  redness.  The  blebs  occur  in  crops,  and 
look  like  small  blisters  filled  with  serum.  They  are  not  met 
Avith  on  the  scalp ;  where  there  are  few  bullse  we  generally  find 
them  on  the  ankle,  or  on  the  hand.  The  disorder  may  be  acute 
or  chronic.  It  is  ordinarily  chronic,  and  happens  in  persons  of 
enfeebled  constitution.  Relapses  are  frequent.  Pemphigus  may 
be  produced  by  the  administration  of  iodide  of  potassium,*  or  by 
syphilis.  SyphilitiG  -pemphigus  is  mainly  met  with  on  the  soles 
of  the  feet  and  the  palms  of  the  hands  of  newly-born  syphilitic 
children.  There  is  a  form  of  extensive  pemphigus  with  flaky 
incrustations  like  eczema, — pemphigus  foliaceus.  But  we  can 
still  find  bullse,  and  there  is  great  attending  prostration. 

Hydroa. — This  is  a  disease  like  herpes,  only  occurring  in  a  more 
diffused  manner  and  presenting  larger  vesicles,  arranged  for  the 
most  part  in  the  form  of  crescentic  rings.  It  is  a  chronic  condi- 
tion, lasting  usually  five  to  eight  months,  and  there  are  in  this 
period  many  acute  or  subacute  outbreaks,  in  which  the  large  ves- 
icles form  and  then  dry  away.  These  attacks  are  attended  Avith 
considerable  itching.  The  base  of  the  vesicle  is  red,  and  it  forms 
out  of  a  red  papule.  The  disorder  happens  chiefly  in  persons  of 
depressed  nervous  system  or  gouty  taint.  It  has  been  confounded 
with  the  eruption  of  bullse  from  iodide  of  potassium ;  but  these 
are  much  larger,  are  more  persistent,  and  leave  a  marked  scar. 

Pustular  Diseases. — These  are  marked  by  circumscribed 
elevations  of  the  cuticle  which  contain  pus.  Acne,  impetigo,  and 
ecthyma  belong  to  the  group.  Rupia,  too,  although  often  classed 
among  the  bullous  disorders,  appertains  more  strictly  to  the  pus- 
tular or  to  the  syphilides. 

*  Bumstead,  Amer.  Journ.  of  Med.  Sci.,  July,  1872. 


91 G  MEDICAL   DIAGNOSIS. 

Acne. — This  is  an  eruption  of  liaid,  isolated,  red  elevations, 
due  to  cjironio  inHanmuition  of  the  sei)aeeous  follieles  and  the 
areolar  tissue  around  them  ;  plugs  of  sebum  are  retained  in  the 
ducts.  At  the  apices  of  many  of  these  elevations  pus  forms, 
Avhich  is  discharged,  leaving  a  hardened  base,  that  only  gradu- 
ally disappears.  Acne  is  generally  seen  on  the  face  and  shoulders. 
Men  of  sedentary  occupations  and  drunkards  are  very  liable  to  it. 
In  women  it  is  frequently  associated  with  uterine  disturbances ; 
in  men,  with  some  genito-urinary  disorder.  An  aene  eruption  also 
follows  the  use  of  tlie  bromides  and  the  iodides  internally,  and 
the  local  use  of  tar.  In  acne  rosacea  lymph  is  generally  eifused 
into  the  papillary'  layer  of  the  skin,  and  some  acne  pustules  are 
mixed  with  the  reddened,  altered  skin.  It  is  a  disease  of  years' 
duration,  but  no  ulcerations  happen. 

Impetigo. — This  is  a  malady  often  happening  in  persons  of  good 
general  health,  and  mostly  soon  ending  in  recovery.  It  presents 
small  jjustules  occurring  in  successive  crops  and  arranged  in  clus- 
ters. The  pustules  are  isolated,  are  little  raised  above  the  surface, 
break,  and  a  thick  yellowish  or  greenish  crust  is  developed ;  no  scar 
follows.  When  the  disorder  attacks  the  scalp  and  face,  especially 
in  infants  and  children,  it  gives  rise  to  very  extensive  incrusta- 
tions, and  constitutes,  particularly  if  conjoined  with  eczema,  the 
affection  designated  as  "  porrigo  larvalis."  There  is  a  contagious 
form  of  it,  described  by  Tilbury  Fox,  which  occurs  acutely,  is 
epidemic,  preceded  by  fever,  and  unattended  with  pain  or  itching. 
Another  form  of  impetigo,  first  mentioned  by  Hebra,  consists  in 
a  multiform  eruption  of  vesicles,  vesico-pustules,  and  pustules. 
This  impetigo  herpetiformis  is  a  rare  disease ;  but  it  has  also 
been  observed  in  this  country.* 

Ecthyma. — This  differs  from  impetigo  by  the  larger  size  and 
greater  prominence  of  the  pustules  and  their  inflamed  base.  When 
the  crust  that  forms  on  each  pustule  falls,  a  highly-congested  sur- 
face or  a  superficial  ulceration  is  seen,  which  leaves  a  cicatrix. 
The  disorder  is  painful,  most  generally  chronic,  and  connected 
with  a  cachectic  state  of  the  system;  irritation  of  the  skin  may 
excite  it.  It  bears  a  certain  resemblance  to  sycosis  ;  but  the  lim- 
itation to  the  hairy  portions  of  the  face,  the  yellow  color  of  the 

*  Duhring,  Medical  News,  Phila.,  June,  1883. 


DISEASES   OF   THE   SKIN.  917 

pustules,  their  conical  form  and  smaller  size,  and  tiie  brown  crusts 
they  occasion,  distinguish  this  malady. 

Rupia. — This  affection  produces  at  first  bullic,  but  soon  very 
large  pustules,  which  desiccate  into  thick,  brownish  crusts,  often 
of  conical  shape  or  resembling  the  shell  of  an  oyster,  which, 
when  thrown  off,  expose  ulcerations  of  various  depth  that  are 
slow  to  heal,  and  on  which  fresh  crusts  arise.  The  disease  runs 
a  chronic  course.  It  occurs  especially  on  the  lower  extremities, 
is  syphilitic,  and  coexists  with  a  deteriorated  constitution.  It  is 
very  like  ecthyma,  and  can  be  distinguished  only  by  the  history 
of  the  case,  the  evidences  of  syphilitic  taint,  the  persistent  ulcer- 
ations, and  the  prominent,  peculiarly-shaped  crusts. 

Squamous  Diseases.  —  The  predominant  characteristic  of 
these  is  the  formation  of  small,  whitish  patches  of  unhealthy 
cuticle  covering  red  papular  elevations  or  a  deep-red,  dry,  some- 
what thickened  surface ;  the  scales  are  generally  very  freely  cast 
off.  Psoriasis  is  the  main  disorder  belonging  to  the  group.  Pity- 
riasis is  included  by  many,  while  others  regard  it  as  merely  a 
variety  of  chronic  erythema,  or  of  eczema.  It  differs  from  lepra 
and  psoriasis  by  the  production  of  minute  scales,  which  are  con- 
stantly thrown  off  and  reformed,  and  which  are  seated  on  a  red- 
dened integument :  hence  its  chief  variety  is  designated  j^ity^'ittsis 
rubra.  It  begins  at  a  special  point,  and,  unlike  psoriasis,  spreads 
over  the  whole  body.  The  skin  is  very  red,  and  not  thickened 
except  in  instances  of  long  standing ;  there  is  no  discharge,  as  in 
eczema,  or  itching  or  burning ;  the  scales  are  loosely  adherent  to 
the  surface,  at  times  they  come  off  in  large  flakes.  The  disease  is 
most  apparent  on  the  body  and  the  limbs ;  in  chronic  cases  the 
general  health  deteriorates. 

Psoriasis. — Here  we  find  patches  of  a  red  hue  raised  above  the 
surrounding  integument  and  covered  by  scales  of  dried  epidermis. 
The  patches  may  have  a  circular  or  circumscribed  shape,  and  the 
scales  be  large  and  well  defined.  But  more  generally  the  scales 
completely  cover  the  morbid  portion  of  skin,  are  small  though 
thick,  pearly  white,  and  the  patches  are  large  or  consist  of  small 
ones  which  have  coalesced  into  a  single  large  one,  are  not  of  an 
annular  form,  and  are  not  completely  separated  by  healthy  skin  ; 
they  are  very  symmetrical. 

Psoriasis  generally  first  ap]3ears  on  the  extensor  surfaces  of  the 


918  MEDICAL    DIAGNOSIS. 

elbow-  and  knee-joints,  and  finally  on  the  face,  where  the  scales 
are  usually  very  small.  As  Beverley  liobinson  has  proved,  the 
morbid  change  begins  in  the  cells  of  the  epidermis.  There 
is  no  watery  discharge,  and  scarcely  any  itching-,  attending  the 
affection. 

Psoriasis  is  often  hereditary ;  in  old  persons  it  is  frequently  of 
gouty  origin.  It  is  a  chronic  affection,  and  extremely  obstinate. 
It  is  liable  to  be  mistaken  for  lichen,  especially  the  isolated  circu- 
lar foi'm  of  it,  the  so-called  lepra.  It  is,  however,  distinguished 
by  the  distinct,  dry,  and  silvery  scales,  and  by  the  smooth,  red, 
perhaps  bleeding  skin  which  is  at  once  perceived  when  the  scales 
are  detached.  Psoriasis  has  a  predilection  for  the  vicinity  of  the 
joints,  especially  the  elboAV-  and  knee  joints.  Sometimes  it  appears 
exclusively  on  the  palm  of  the  hand ;  and  in  this  form  especially 
we  are  apt  to  find  deep  cracks.  Psoriasis  difiters  from  eczema 
squamosum  by  the  latter  having  preceding  vesicles  and  severe 
itching  and  showing  the  want  of  uniformity  of  lesion.  Indeed, 
psoriasis  is  distinguished  from  all  forms  of  eczema  by  the  absence 
of  fluid  effusion  at  any  time  in  the  history  of  the  case.  In  scaly 
syphilitic  eruption  the  scales  are  comparatively  few  and  fine; 
when  they  are  removed,  the  dense  skin  underneath  does  not 
bleed ;  and  the  eruption  is  not  likely  to  be  met  with  on  the 
elbows  and  the  knees. 

Ichthyosis. — Fish-skin  is  also  a  squamous  disease  ;  but  it  differs 
from  the  others  of  this  class  in  being  much  more  general,  in- 
volving as  it  does  often  the  whole  integument,  and  in  the  ab- 
sence of  reddening  or  any  signs  of  inflammation  of  the  harsh, 
dry  surface ;  it  is,  indeed,  an  hypertrophy  of  the  cuticle.  The 
skin  is  dry,  dirty,  and  rough,  and  covered  with  thickened  and  ex- 
foliating cuticle  and  with  sebum  ;  there  may  also  be  fissures  and 
cracks.  Ichthyosis  is  almost  always  of  congenital  origin ;  it 
affects  the  whole  body,  though  the  face  but  very  slightly. 

Among  the  inflammatory  diseases  of  the  skin,  those  resulting 
from  medicines  taken  into  the  system  may  be  here  mentioned. 
This  dermatitis  medicamentosa  is  brought  about  by  a  variety  of 
drugs,  and  differs  largely  according  to  the  special  drug.  Among 
the  principal  ones  producing  morbid  appearances  of  the  skin  are 
arsenic,  quinine,  belladonna,  opium,  chloral,  salicylic  acid,  anti- 
pyrin,  the  bromides,  the  iodides.      The  acneform  eruption  due  to 


DISEASES   OF   THE   SKIN.  919 

the  bromides,  with  the  dusky-red  coh^r  oi'  pai'is  of"  th(!  skin,  or 
the  ulcers  they  may  occasion  ;  the  papular  or  l)ull(jiis  eruption 
caused  by  the  iodides,  especially  by  the  iodide  of  potassium;  and 
the  scarlet  rash  of  belladonna, — are  well  known. 

Maculae. — These  include  stains  on  the  skin  which  are  due  to 
chemical  substances,  such  as  nitrate  of  silver,  or  blood-spots,  as 
in  purpura,  or  spots  in  consequence  of  parasitic  formations,  as  in 
tinea  versicolor.  But  their  chief  cause  is  increased  pigmentation; 
and  it  is  this  cause  that  we  shall  look  at  more  particularly. 

First,  lentigo  may  be  mentioned.  This  consists  of  the  little 
yellow  or  yellowish-brown  spots  which  are  so  often  met  with  on 
the  face  and  on  the  arms  in  children  under  eight  years  of  age,  and 
which,  if  they  have  persisted,  disappear  in  middle  life.  Simi- 
lar spots  are  ephelides,  or  freckles ;  these,  though  aggravated  by 
exposure  to  the  sun,  may  exist  all  the  year  round.  Melasma 
is  a  very  dark  pigmentation,  which,  although  it  has  been  met 
with  in  an  epidemic  form,  is  commonly  seen  in  connection  with 
Addison's  disease. 

Chloasma  consists  of  a  brownish  or  yellowish-brown  pigmen- 
tation, giving  rise  to  the  so-called  liver  spots.  They  are  smooth 
and  well-defined  maculse  without  scales,  and  may  result  from  any 
local  irritation  or  from  exposure  to  the  sun.  They  may  also 
happen  in  cases  of  faulty  digestion  with  torpor  of  the  liver,  in 
uterine  disorders,  and  in  the  pregnant  state.  Tinea  versicolor  is 
constantly  confounded  with  these  so-called  liver  spots.  But  it 
is  almost  entirely  a  disease  of  the  trunk,  is  much  more  itchy, 
is  slightly  raised,  and  in  the  scales  w^e  scrape  off  is  found  the 
characteristic  fungus. 

New  Growths. — These  are  hard,  indolent,  and  often  per- 
manent tumors  of  the  skin,  which  in  their  main  forms  consist 
of  granulation  tissue.  Lupus  and  elephantiasis  of  the  Greeks 
mainly  illustrate  this  group. 

Lupus. — In  lupus  a  tissue  is  formed  like  granulation  tissue,  and 
the  new  growth  mostly  takes  place  in  the  form  of  isolated  tuber- 
cles. These  may  or  may  not  ulcerate.  They  are  of  a  dull-red 
color,  elevated  above  the  surface,  have  a  well-defined  outline, 
spread  outward  into  normal  textures,  and,  if  they  ulcerate,  de- 
stroy the  tissues  in  which  they  are  situated.  The  ulcers  also 
spread,  and  may  occasion  much  devastation.     When  they  heal, 


920  MEDICAL   DIAGNOSIS. 

they  leave  a  strongly-marked  whitish  cicatrix  and  an  unheal thv- 
looking  skin.  The  disorder  occurs  in  syphilitic  or  in  scrofulous 
pei*sons,^-generally  in  the  latter, — appears  often  in  childhood^  is 
attended  with  some  pain  and  itching,  and  pursues  a  very  slow 
course.  The  nose  and  cheek  are  the  favorite  sites.  There  is  a 
form  of  lupus  occurring  only  in  strumous  subjects,  and  charac- 
terized by  warty  formations.  This  lupus  verrucosus  is  without 
pain  or  itching,  but  cicatrices  form,  though  there  has  been  no 
previous  ulceration.*  In  lujms  erythematodes  the  disease  is  super- 
ficial, and  the  sebaceous  glands  particularly  are  distended.  The 
surface  is  somewhat  raised,  the  centre  of  the  diseased  patch  is  pale 
and  sinks  in.  The  tubercles  form  late,  if  at  all,  and  there  is  no 
ulceration.  The  most  common  site  of  the  disease  is  under  the  eye. 
It  does  not  generally  appear  until  after  puberty,  and  is  preceded 
by  erythema  of  the  aifected  parts. 

Lepra. — Leprosy  is  a  chronic  constitutional  disorder,  and  the 
symptoms  of  general  depression  may  precede  the  characteristic 
local  features.  The  true  leprosy,  the  elephantiasis  of  the  Greeks, 
is  distinguished  by  tubercles,  from  the  size  of  a  pea  to  that  of  a 
walnut,  of  reddish  or  whitish  or  bronze-like  hue,  which  slowly 
idcerate,  and  which  are  preceded  by  erythematous  j)atches;  ulcera- 
tion is  apt  to  take  place  about  the  fingers  and  toes.  Like  lupus, 
the  tubercles  have  the  structure  of  granulation  tissue.  Often, 
too,  there  are  symptoms  of  defective  innerv^ation,  especially  de- 
ficient sensation  of  the  surface,  the  nerve-trunks  are  invaded,  cuta- 
neous eruptions  in  their  course  result,  and  the  blood  is  seriously 
affected.  The  face  is  most  frequently  the  seat  of  the  malady,  and 
becomes  very  much  thickened  and  disfigured ;  similar  changes 
may  also  be  seen  in  the  limbs.  Pemphigus-like  blebs  are  among 
the  earliest  signs.  When  marked  nodules  form,  the  skin  is  de- 
cidedly discolored,  often  copper-colored,  and  the  face  is  distorted 
and  has  a  fierce  expression.  Sometimes  anesthesia  is  the  main 
symptom,  and  the  uneven  thickening  may  occur  in  circular 
patches  like  psoriasis,  but  without  tubercles,  and  be  markedly 
anaesthetic.     The  disease  is  often  hereditary. 

Two  forms  of  the  disease  are  generally  recognized, — ^the  tu- 
bercular and  the  anaesthetic ;  but  there  is  no  absolute  distinction 

*  McCall  Anderson,  Journal  of  Cutaneous  Medicine,  vol.  L 


DISEASES   OF   THE   SKIN.  021 

between  them.  The  disease  is  common  in  tropical  regions,  es- 
pecially the  East,  and  in  Africa  and  Brazil ;  it  is  also  found  in 
Norway,  and  in  the  Sandwich  Islands,  and  is  not  unknown  in 
the  United  States.* 

Hypertrophies. — There  are  many  forms  of  these,  according 
to  whether  the  connective  tissue,  the  epidermis,  the  arteries  and 
veins,  or  the  lymphatic  vessels  are  affected.  I  shall  notice  par- 
ticularly two  ;  and  first,  elephantiasis  Arabum. 

Elephantiasis  of  the  Arabs. — This,  the  Barbadocs  leg,  is  an 
enormous  increase  in  size  of  the  limb,  usually  dependent  upon  an 
indurated  swelling  of  the  subcutaneous  tissues,  with  some  altera- 
tion of  the  skin  proper,  and  lymphangitis.  The  tumefaction  may 
be  in  swellings  separated  by  deep  furrows,  giving  somewhat  of  a 
tuberculated  look  to  the  part,  or  it  may  be  uniform ;  it  chiefly 
attacks  males,  and  gives  rise  to  great  deformities.  It  is  a  dis- 
ease of  the  tropics.  The  cases,  especially  of  elephantiasis  of  the 
scrotum,  have  been  frequently  traced  to  filarise. 

There  is  a  form  of  enlargement  of  the  leg  to  which  we 
may  here  briefly  refer,  —  one  in  which  the  overgrowth  of  the 
affected  limb  is  associated  with  disease  in  the  lymj^hatic  system. 
Vesicles  form,  which  are  connected  by  ridge-like  elevations,  and 
which  from  time  to  time  discharge  a  chylous  fluid.f  The  sub- 
cutaneous lymphatics  near  the  groin  are  usually  found  to  be 
distended. 

Scleroderma. — Scleroderma,  or  sclerema,  is  an  induration  of 
the  skin  and  areolar  texture,  which  may  be  partial  or  general, 
affecting  nearly  the  whole  body.|  The  skin  is  dense  and  hard, 
and  in  the  true  skin  and  the  subcutaneous  tissue  the  fibrous  ele- 
ments are  much  increased.  The  true  skin  shrinks  and  binds 
down  and  is  bound  to  the  parts  beneath.  If  the  malady  seize 
upon  the  fingers,  it  renders  them  rigid  and  immovable.  The 
disease  is  generally  symmetrical,  and  is  much  more  common  in 
women  than  in  men.  It  frequently  coexists  with  feeble  health  ; 
and  in  time  the  internal  organs  become  affected,  or  these  may  be 

*  See  Transact.  Amer.  Dermatol.  Assoc,  1879,  and  Henry  Dickson  Bruns, 
Archives  of  Medicine,  New  York,  Dec.  1881. 

t  W.  H.  Day,  Transact.  Clin.  Soc.  Lond.,  vol.  ii.,  1869. 

X  See  the  cases  collected  by  Van  Harlingen,  Amer.  Journ.  of  Syphilograpliy 
and  Dermatology,  1873. 


922  MEDICAL   DIAGNOSJS. 

from  the  fii*st^  deeply  implieated.*  The  general  health  may, 
however,  remain  good. 

I  had  some  years  sinee  a  marked  case  of  this  strange  affection 
under  my  charge  at  the  Pennsylvania  Hospital,  in  a  woman,  forty- 
two  years  of  age,  who,  admitted  with  oedema  of  the  feet,  M'as  at 
the  same  time  noticed  to  have  a  swelling  of  both  wrists  and  fore- 
arms as  well  as  of  the  cheeks.  The  swelling  was  firm  and  resist- 
ant, and  did  not  pit  on  pressure.  The  skin  covering  it  was  very 
smooth,  and  of  redder  hue  than  at  other  portions  of  the  body; 
there  was  well-preserved  sensibility.  The  oedema  disappeared 
from  the  feet,  but  the  signs  of  the  indurated  cellular  tissue  did 
not  leave  the  affected  parts.  On  the  contrary,  the  condition  of 
these  parts  became  worse,  though  the  general  health  was  excellent, 
all  the  internal  viscera  being  in  a  normal  state.  Gradually  the 
hands,  particularly  the  fingers,  were  found  to  be  more  and  more 
resisting  and  immovable,  and  she  could  scarcely  bend  them  ;  occa- 
sionally they  were  the  seat  of  pain.  The  skin  lost  all  suppleness, 
and  could  not  be  raised  up.  At  no  time  while  under  observation 
was  albumen  present  in  the  urine.  She  left  the  hospital  unim- 
proved by  the  sulphur  baths,  the  bichloride  of  mercury,  and  the 
various  other  alteratives  she  took  ;  and  I  afterward  learned  that 
she  died  of  an  acute  pleurisy  succeeding  an  attack  of  acute  men- 
ingitis from  which  she  had  not  wholly  recovered.  Prior  to  her 
death,  so  great  was  the  pressure  exerted  by  the  dense  and  con- 
tracting cellular  tissue  that  dry  gangrene  of  a  finger  ensued,  as 
well  as  of  a  toe,  the  disease  having  also  been  noticed  in  the  lower 
extremities.  She  died  about  one  year  from  the  beginning  of  the 
complaint.  Examined  after  death,  the  skin  over  the  diseased 
parts  was  found  to  be  firmly  united  by  the  dense  and  augmented 
areolar  textures  to  the  muscles  beneath. 

Scleroderma  is  very  similar  in  many  of  its  features  to  myx- 
cedema.  But  the  marked  anaemia'  of  this,  the  decided  nervous 
symptoms,  and  the  fact  that  we  do  not  find  the  stiff,  hard  skin 
compressing  the  parts  beneath  and  bound  to  them  causing  in  time 
marked  atrophies,  distinguish  the  two  maladies.  Repeated  attacks 
of  erysipelas  thicken  the  skin,  but  we  do  not  find  the  atrophies 
from  compression. 

*  Harley,  Med.-Chir.  Transact.,  1877. 


DISEASES   OF   THE   SKIN.  923 

Scleroderma  is  closely  related  to  morphcea.  This  frequently 
occurs  over  the  course  of  nerve  tracts,  the  thickening  is  in  cir- 
cumscribed patches  and  lacks  the  peculiar  hardness  of  sclerema ; 
on  the  other  hand,  changes  in  the  structure  of  the  skin,  hyper- 
semic  appearances  at  first,  pigmentation  and  cicatrization  after- 
ward, occur  in  morphoea,  with  pain  and  tingling  in  the  affected 
parts. 

Parasitic  Diseases. — These  may  be  caused  by  the  presence 
either  of  parasitic  animals  or  of  plants.  To  affections  of  the 
former  origin,  or  to  the  epizoa,  belongs  especially  scabies ;  though 
the  various  forms  of  lice  producing  the  ailment  presenting  for  the 
most  part  a  pruriginous  eruption  with  little  hemorrhagic  marks — 
phtheiriasis — must  be  mentioned.  Another  animal  parasite,  the 
entozoon  or  demodex  folliculorum,  inhabits  the  sebaceous  and  hair 
follicles,  but  does  not,  so  far  as  is  known,  cause  disease. 

The  complaints  associated  with  the  vegetable  parasites,  the  epi- 
'phytes,  or,  as  those  on  the  skin  are  called,  the  dermatophytes,  also 
known  by  the  generic  name  of  tinea,  are  chiefly  favus,  mentagraj 
pityriasis  versicolor,  and  some  of  the  forms  of  ringworm,  tinea 
circinata,  and  tinea  tonsurans.  Pellagra,  also  supposed  to  be  due 
to  a  vegetable  jiarasitic  growth,  is  not  an  affection  met  with  in  this 
country.  Nor  does  the  presumed  parasitic  fungus  lodge  in  the 
skin.  It  is  said  to  be  found  in  diseased  Indian  corn  or  maize, 
which,  when  eaten,  causes  the  general  cachexia  and  cutaneous 
eruption  Avhich  characterize  the  malady,  of  which  the  eruption, 
moreover,  is  determined  by  exposure  to  the  sun. 

Scabies. — Scabies,  or  the  itch,  is  owing  to  the  acarus  scabiei. 
This  burrows  into  the  skin,  particularly  between  the  fingers  and 
between  the  toes,  about  the  wrists,  and  on  the  buttocks  and  ab- 
domen and  the  upper  part  of  the  penis.  The  channels  produced 
are  generally  somewhat  curved,  and  may  be  traced  as  whitish  or 
more  generally  black  streaks  several  lines  in  length,  in  the  situa- 
tions jiist  indicated.  The  disease  is  attended  with  excessive  itch- 
ing, which  is  increased  at  night,  and  with  the  eruption  of  conical 
vesicles,  or  even  of  a  marked  eczema  and  of  papules  and  pustules ; 
most  of  the  rash  is  due  to  the  irritation  of  scratching. 

At  the  close  of  our  civil  war  we  had  a  form  of  itch  very 
prevalent  in  this  country,  which  was  spread  far  and  A^ade,  as  is 
presumed,  by  contact  with  the  troops, — the  so-called  army  itch. 


924 


MEDICAL    DIAGNOSIS. 


It  was  a  chronic  and  distressing  affection,  and  no  age  or  social 
state  was  exempt  from  it.  Indeed,  so  prevalent  was  it  that  it 
almost  appeared  as  an  epidemic.  The  itching  was  intense ;  the 
eruption,  as  by  far  most  fi'equcntly  met  with,  was  like  prurigo, 
but  vesicles,  or  even  an  eezematous  condition  of  the  skin,  or  pus- 

FiG.  71. 


A  female  acanis,  taken  from  a  photograph  from  nature ;  magnified 
220  diameters.     The  ventral  Burface  is  shown. 


tules,  attended  the  intolerable  itching ;  and  in  cases  of  very  long 
duration  the  appearance  of  the  skin  was  altered,  and  all  trace  of 
a  distinctive  eruption  was  gone.  The  eruption  was  seen  on  the 
arms,  forearms,  chest,  abdomen,  and  lower  extremities,  particularly 
on  the  ulnar  side  of  the  forearm  and  the  inner  aspect  of  the  thigh. 
It  was  sometimes  found  on  the  scalp,  but  very  seldom  in  the 
groins,  in  the  axillae,  on  the  hands,  or  between  the  fingers.  It 
was  benefited  by  sulphur ;  for  almost  all  the  preparations  recom- 
mended for  it  contained  sulphur.  Whether  it  was  due  to  the 
same  acarus  as  ordinary  scabies,  or  to  a  different  species,  I  am 
unable  to  say. 

Tinea  Favosa. — Tinea  favosa,  or  favus,  is  a  chronic  '  disease 
which  gives  rise  to  bright-yellow  umbilicated  crusts,  of  circular 
shape  and  smooth  surface,  Avhich  often  form  yellow  rings  around 
the  hair  follicles  and  are  not  much  elevated  above  the  skin. 
There  is  no  discharge.  The  disease  rarely  affects  any  other  part 
of  the  body  than  the  scalp,  and  produces  baldness ;  when  the  nails 
are  attacked,  they  become  brittle  and  yellow.     In  cases  of  doubt, 


DISEASES   OF   THE    SKIN.  925 

the  microscope  furnishes  us  Avith  a  certain  means  of  diagnosis,  by 
exhibiting  the  cryptogamic  plants. 

Tinea  Sycosis. — Of  tinea  sycosis  it  is  prol)ab]e  that  there  is  a 
non-parasitic  as  well  as  a  parasitic  form.  TJie  distinctive  mar]<s  of 
the  disease  consist  in  the  development  of  yellowish  pustules,  Jiaving 
a  bright-red  base,  around  the  roots  of  the  hair  of  the  iK'ard ;  the 
hairy  portion  of  the  neck  may  also  be  affected.  The  crusts  may 
run  together,  and  more  or  less  inflammatory  thickening  of  the 
skin  exists.  This  is  especially  seen  in  the  parasitic  form  of  the 
disease,  in  which,  however,  less  suppuration  happens,  and  less 
pain  or  itching,  but  in  which  the  hairs  become  brittle  and  lose 
their  healthy  look.  The  upper  lip  is  rarely  implicated  in  tinea 
sycosis.  Non -parasitic  sycosis  consists  chiefly  in  an  inflammation 
around  the  follicles,  which  always  starts  in  these  parts.* 

Tinea  Circinata  and  Tinea  Tonsurans. — The  trichophyton  ton- 
surans is  the  parasite  met  with  in  tinea  circinata,  the  ringworm 
of  the  body,  and  in  tinea  tonsurans,  the  ringworm  of  the  scalp. 
This  is  common  in  children,  and  spreads  by  contagion.  It  exists 
in  circular  scaly  patches,  on  which  are  dry  broken  hairs.  In 
ringworm  of  the  body  the  patches  are  also  circular  and  scaly; 
but  they  are  red  and  very  itchy,  and  much  paler  in  the  centre 
than  at  the  edge.  Examining  the  scurf,  we  find  the  fungous 
growth.     Tinea  kerion  is  a  suppurative  form  of  tinea  tonsurans. 

Tinea  Versicolor. — This  parasitic  affection,  also  known  as  pityri- 
asis versicolor,  occasions  those  yellow  or  yellowish-brown  discol- 
orations  which  may  be  not  unfrequently  seen  on  various  parts  of 
the  body.  The  affection  is  common  in  women,  especially  in  preg- 
nant women.  The  microsporon  furfur  of  Eichstiidt  is  the  parasite 
present  in  this  disorder;  and  it  is  found  abundantly  in  the  scales 
which  can  be  scraped  from  the  raised,  itching  patches.  In  pity- 
riasis affecting  the  scalp  we  may  also  find  parasitic  growths  of 
vegetable  nature ;  they  are  often  the  cause  of  baldness,  as  in  tinea 
decalvans. 

Altered  Gland-secretions. — One  of  these,  seborrhoea,  or  in- 
creased secretion  from  the  sebaceous  glands  mixed  with  ejDidermic 
scales,  has  already  been  mentioned.  It  is  especially  found  on  the 
scalp,  nose,  and  genitals,  and  is  often  seen  among  those  who  have 


*  Eobinson,  New  York  Medical  Journal,  Aug.  and  Sept.  1877. 


926  MEDICAL   DIAGNOSIS. 

menstrual  disorders.  It  is  unattended  by  itching ;  the  crusts  are 
readily  removed  by  strong  alkaline  soaps,  and  the  skin,  beneath  is 
healthy,  or  pale  and  glistening  or  slightly  reddened. 

Where  the  sebum  is  retained  in  the  follicle,  giving  rise  to  little 
prominences,  apt  to  be  discolored  by  dirt,  and  without,  as  happens 
in  acne,  decided  inflammation  around  the  gland  and  its  duct,  tiie 
disorder  is  called  comedo.  The  plug  of  sebum  can  be  easily 
squeezed  out.  The  disorder  is  most  common  on  the  face  and 
shoulders  of  young  persons  of  lymphatic  temperament. 

The  sweat-glands  are  often  altered  in  their  activity,  and  excess- 
ive perspiration  results.  This  may  be  general,  or  confined  to 
particular  localities,  as  to  the  hands  and  feet.  This  local  sweat- 
ing is  often  offensive,  and  makes  the  parts  very  tender.  At  times 
there  is  sweating  of  blood  from  the  skin,  as  in  the  case  recorded 
by  Hart.* 

Molluscum  presents  numerous  globular  or  flattish  nodules,  some- 
times seated  on  a  broad  base  or  attached  to  a  pedicle.  They  are  due 
to  excessive  enlargement  and  distention  of  the  sebaceous  glands. 
They  occur  chiefly  in  groups  on  the  face  and  neck,  or  on  the 
trunk,  have  often  a  doughy  feel,  vary  in  size  from  that  of  a  pea  to 
that  of  a  pigeon's  egg,  grow  even  to  be  larger,  show  no  tendency  to 
inflame  or  ulcerate,  and  are  not  attended  with  increased  sensibility 
of  surface.  They  are  of  the  color  of  the  skin  or  of  brownish  hue. 
They  may  last  during  life  and  increase  slowly  without  affecting 
the  general  health.  There  is  a  variety  met  with  especially  in 
children,  which  has  at  the  top  or  side  of  each  tubercle  a  small 
orifice,  from  Avhich  a  creamy,  fatty  fluid  can  be  pressed.  This 
variety  is  regarded  as  contagious ;  though  there  are  many  ^vho 
doubt  the  contagious  nature  of  "  molluscum  contagiosum."  The 
little  tumors  are  distinguished  from  fibromata  by  the  central  aper- 
ture, and  by  the  sebum  that  can  be  squeezed  out  of  them. 

Nervous  Affections. — These  are  of  many  varieties.  Several 
of  these,  such  as  herpes  zoster,  have  already  been  considered.  The 
large  group  of  itching  affections  where  no  very  obvious  local  affec- 
tion exists,  find  here  their  place.  Such  are,  for  instance,  the  various 
forms  of  pruritus,  either  local  or  general,  which  are  specially  apt 
to  befall  elderly  persons.     Sometimes  the  itching  is  very  violent 

*  Louisville  Medical  Journal,  Jan.  1875. 


DISEASES   OF    THE    SKTN.  927 

and  obstinate,  and  we  cannot  even  trace  it  to  reflected  irritation, 
though  this  is  often  its  cause.  Again,  diahetes,  gout,  lithicniia, 
or  jaundice  may  lie  at  the  root  of  the  pruritus.  At  times  we  can 
find  no  cause  for  it.  Season  influences  it  much,  as  seen  in  the 
winter  itching,  the  pruritus  hiemalis,  described  by  Duhring.  It 
happens  particularly  about  the  thighs  and  legs,  and  there  may  be 
prominence  of  the  hair  follicles.  Among  the  other  manifestations 
of  nervous  skin  affections  are  dermatalgia,  hypersesthesia,  anaes- 
thesia ;  then  there  are  undoubtedly  cutaneous  diseases  which  are 
being  more  and  more  recognized  as  of  nervous  origin. 

The  disorders  of  the  skin  which  Ave  have  been  considering  do 
not  always  occur  isolated  ;  they  may  be  combined.  Again,  they 
are  altered  by  the  existence  of  a  special  taint,  as  by  the  syphilitic. 
Now,  without  making  any  attempt  to  describe  syjohilitic  diseases 
of  the  skin,  it  may  briefly  be  stated  that  they  difi'er  chiefly  by 
their  copper -colored  tint,  by  the  stained  aspect  they  leave,  and  by 
the  absence  of  pain  and  of  itching.  In  syphilitic  erythema  the 
eruption  runs  a  very  chronic  course,  and  is  very  distinct  generally 
on  the  trunk.  It  belongs  to  early  syphilis.  Syphilitic  lichen  has 
better-defined,  more  obvious  papules  than  simple  lichen.  The 
ulcerations  in  the  pustular  affections  are  deeper ;  while  in  the 
squamous  disorders  the  scabs  are  smaller  and  -  the  papules  larger 
than  in  the  non-syphilitic  eruptions.  A  furunculoid  eruption  is 
occasionally  met  with  in  hereditary  syphilis.  Syphilitic  affections 
of  the  skin  are  very  apt  to  be  mixed,  and  light  is  thrown  on  them 
by  this  fact,  as  well  as  by  the  history  of  the  case,  the  sore  throat, 
the  falling  of  the  hair,  and  the  nerve-  and  bone-pains. 


CHAPTER   XIV. 

POISONS   AND   PARASITES. 

In  disorders  due  to  poisons  or  parasites,  the  morbid  phenomena 
are  clearly  occasioned  by  causes  introduced  into  the  system  from 
without.  Thus  they  agree  in  being  affections  of  external  origin ; 
and  as  regards  both  the  diagnosis  and  the  treatment,  our  chief  aim 
is  to  ascertain  precisely  to  what  foreign  substance  the  symptoms 
are  due. 

POISONS. 

Cases  of  poisoning  may  arise  from  accident,  attempt  at  sui- 
cide, or  criminal  intent.  It  is  not  necessary  here  to  enter  at  any 
length  into  the  subject  of  toxicology,  but  merely  to  set  forth  the 
main  signs  by  which  the  most  common  poisons  may  be  recognized 
and  distinguished.  For  this  purpose  it  will  be  convenient  to 
consider  the  cases  as  divided  into  acute  and  chronic,  subdividing 
these  classes  according  to  the  character  and  effects  of  the  different 
substances. 

Acute  Poisoning. 

TJie  attack  comes  on  suddenly,  the  patient,  previously  in  perfect 
health,  having  taken  some  food,  drink,  or  medicine  ^vhich  has 
been  followed  by  the  severe  symptoms.  It  is  always,  in  a  case 
of  suspected  poisoning,  of  the  utmost  importance  to  be  able  to 
make  out  these  points. 

Irritant  Poisons. — The  chief  articles  which  give  rise  to 
acute  poisoning  belong  to  the  class  of  irritant  poisons.  The 
symptoms  are  generally  those  of  acute  gastritis,  attended  often 
with  more  or  less  inflammation  of  the  mouth,  the  fauces,  and  the 
oesophagus.  Sometimes  the  air-passages  may  be  involved,  either 
directly  or  by  sympathy,  and  we  find  lioarseness  and  cough. 
Convulsions  are  occasionally  observed,  and  collapse  is  apt  to  occur 
sooner  or  later. 
928 


POISONS   AND    PARASITES,  1J29 

The  acute  pain,  the  tendci'iiess,  and  th(!  vomiting  come  on 
shortly  after  a  meal,  or  at  least  after  something  lias  been  swal- 
lowed. This  distingnishes  the  acute  gastritis  caused  by  poisons 
from  idiopathic  acute  gadritis  or  from  acute  cjaMiic  catarrh  ;  and 
sometimes  several  persons  are  similarly  affected, — a  circumstance 
always  strongly  in  favor  of  the  idea  of  poisoning.  From  perfora- 
tion of  the  stomach  or  intestines,  irritant  poisoning  is  discriminated 
by  noting  that  the  acute  signs  in  the  former  case  follow  upon  the 
manifestations  of  some  gastric  or  intestinal  affection  ;  and  the  at- 
tending phenomena  of  collapse  are  not,  as  in  poisoning,  associated 
with  cramps  or  convulsions.  Cholera  morbus  is  separated  by  the 
history  of  the  case,  by  the  absence  of  epigastric  tenderness,  and  by 
the  purging  and  vomiting  often  coming  on  simultaneously.  Cholera 
resembles  poisoning  in  the  suddenness  and  the  violence  of  the 
attack,  but  is  distinguished  by  the  rice-water  discharges  and  by 
its  epidemic  character.  In  strangulated  hernia,  the  comparatively 
gradual  onset,  the  pain,  the  tumor,  and  the  constipation  w'ill  l)e 
significant.  As  regards  the  separation  of  those  cases  of  poisoning 
in  which  blood  is  ejected,  from  ordinary  hemorrhage  from  the 
stomach,  we  find  that  pain  and  purging  are  both  absent  iu  the 
latter,  while  in  irritant  poisoning  they  are  well-marked  symptoms. 

Let  us  now  examiiie  some  special  poisons.  Strong  acids  are 
frequently  used  to  destroy  life.  Nitric  acid  stains  the  lips  and 
mouth  orange-yellow  wherever  it  touches  them.  Sulphuric  acid 
stains  the  skin  or  mucous  membrane  white  or  even  dark  gray ; 
the  pain  is  excessive,  and  nervous  symptoms  are  not  infrequent, 
and  if  the  vomited  matter  be  mixed  Avith  a  solution  of  nitrate  of 
barium,  a  dense  wdiite  precipitate  of  sulphate  of  barium  is  thrown 
down.  Hydrochloric  acid  is  less  irritant  and  corrosive  than  sul- 
phuric acid;  in  the  ejected  matter  nitrate  of  silver  produces  a 
white  precipitate.  Oxcdic  acid,  when  concentrated,  is  rapidly  fatal. 
The  irritant  effects  are  those  of  the  mineral  acids ;  but  we  also 
meet  with  dyspnoea  and  with  nervous  phenomena,  such  as  anaes- 
thesia, parsesthesia,  palsies,  and  convulsions. 

The  strong  alkcdies,  when  taken  into  the  stomach,  cause  inflam- 
raation  of  the  organ  and  of  the  fauces  and  the  oesophagus.  Should 
the  case  end  in  recovery  from  the  poisonous  influence,  thickening 
of  the  oesophagus  is  apt  to  occur.  Ammonia  may  also  induce 
severe  nervous  symptoms,  similar  to  those  of  tetanus ;  its  vapor 

59 


930  MEDICAL   DIAGNOSIS. 

sometimes  acts  poAverfully  on  the  air-passages,  producing  harass- 
ing cough.  Pot((,muiii  and  so(JiHiii  lij/drafcs  give  rise  to  violent 
local  inflammation  in  the  mouth,  cesophagus,  and  stomach.  The 
vomited  matter  has  an  alkaline  reaction.  Potasfiiitni  nitrate  is 
a  strong  cardiac  sedative. 

Potasfiliun  iodide,  iodine,  bromine,  and  cldorine  are  all  capable 
of  destroying  life  by  their  intensely  irritant  effect. 

Phosphorus,  -which  is  not  unfrequently  taken  as  a  poison,  imparts 
to  the  breatli,  to  the  ffeces,  and  even  to  the  urine,  an  alliaceous 
smell,  and  makes  them  luminous  in  the  dark.  It  acts  as  an  irri- 
tant, causing  obstinate  vomiting  and  purging,  pain  at  the  epigas- 
trium, rapid  and  weak  pulse,  jaundice,  and  unquenchable  thirst. 
The  local  pain  and  iuflanmiation  are  usually  extreme,  and  col- 
lapse, with  or  without  convulsions,  comes  on  early.  In  some 
eases  painful  cram])s  in  the  limbs  occur,  and  various  disturb- 
ances of  sensibility,  and,  later,  violent  delirium  and  convulsions, 
eventuating  in  coma  and  in  death.  In  other  cases  hemorrhage  is 
a  striking  feature,  the  blood  is  very  fluid,  and  issues  from  all  the 
passages,  and  petechise  form  beneath  the  skin.  The  tempera- 
ture remains  normal  until  near  death.  The  pulse  becomes  feeble 
and  small ;  the  first  sound  of  the  heart  almost  disappears ;  pep- 
tonuria is  observed.*  Jaundice  is  a  constant  symptom  ;  it  seldom, 
however,  comes  on  before  the  third  day,  and  is  rarely  intense ;  it 
may  be  associated  with  urticaria.  The  spleen  increases  in  size 
simultaneously  with  the  liver.  The  urine  becomes  very  scanty. 
Albumen,  blood,  and  casts  are  occasionally  present  in  the  secre- 
tion, and  the  biliary  coloring-matter  is  usually;  urea  is  very  de- 
fective. In  cases  of  phosphorus  poisoning,  acute  and  extreme  fatty 
degeneration  of  the  tissues  happens.  It  occurs  with  astonishing 
rapidity.  It  has  been  seen,  in  the  bodies  of  j^ersons  poisoned  by 
phosphorus,  Avithin  so  short  a  period  as  forty-eight  hours,  and  lias 
been  found  to  affect  the  heart,  the  smaller  blood-vessels  and  ca])il- 
laries,  the  liver,  the  kidneys,  the  glands  of  the  stomach,  and  the 
voluntary  muscles.f     The  liver  is  always  principally  implicated. 

Various  salts  of  potassium,  copper,  zinc,  silver,  lead,  and  iron 


*  L'Abeille  Medicale,  July,  1882,  quoted  in  Medical  News,  Phila.,  vol.  11., 
1882;  also  Jaksch,  Wien.  Med.  Presse,  Oct.  1882. 

f  Tardieu,  Etude  medico-legale  sur  I'Enipoisonnement,  1867,  p.  445. 


POISONS    AND    PARASITJ-:S.  031 

occasionally  cause  death.  They  act,  for  the  most  part,  as  irritants 
merely ;  but  some  of  tliem  arc;  powerfully  astringent,  and  ev(,'n 
caustic,  as,  for  instance,  the  chh)ride  of  zinc  or  the  nitrate  of  silver. 
If  the  toxical  phenomena  are  due  to  the  nitrate  of  silver,  the  stain- 
ing of  the  lips  mayjfifford  a  clue  to  the  nature  of  the  case.  There 
are  no  really  distinctive  symptoms  produced  by  large  doses  of 
arsenic,  of  antimony,  of  mercury,  or  of  their  compounds,  which 
are  among  the  best  known  of  irritant  poisons  :  the  peculiar  effects 
of  each  of  these  substances,  when  insidiously  introduced  into  the 
economy,  will  be  ])resently  mentioned.  In  acute  arsenical  poison- 
ing, besides  the  pain  and  the  gastro-enteric  symptoms,  convul- 
sions, delirium,  palsies,  and  bloody  or  albuminous  urine  have  been 
specially  noticed.  Arsenical  poisoning  is  a  very  common  form  of 
self-destruction.  It  is  also  observed  among  those  who  accidentally 
take  Scheele's  green,  or  among  children  who  swallow  arsenical 
paints.  There  is  in  the  internal  organs  a  fatty  degeneration  sim- 
ilar to  that  in  phosphorus  poisoning.  In  the  recognition  of  the 
cause  of  the  symptoms,  Marsh's  test  for  arsenic,  applied  to  the 
vomited  matter,  plays  an  important  part.  In  poisoning  by  corro- 
sive sublimate,  epigastric  pain,  vomiting,  diarrhoea,  bloody  stools, 
and  finally  collapse,  are  met  with. 

Among  animal  substances,  cantharides  has  sometimes  been  pro- 
ductive of  poisonous  effects ;  strangury,  bloody  urine,  albumi- 
nuria, more  permanent  than  that  produced  by  turpentine,  priapism, 
and  spasm  of  the  glottis,  are  the  most  marked  symptoms ;  while 
the  shining,  green  particles  of  the  drug,  if  taken  in  substance, 
have  been  detected  in  the  vomited  matters. 

Sausage,  milk,  cheese,  eggs,  especially  in  articles  of  confectionery, 
such  as  cream  puffs,  frequently  produce  violent  symptoms  sug- 
gesting some  of  the  more  powerful  irritants,  although  chemical 
examination  fails  to  reveal  any  mineral  poison.  The  researches 
of  Vaughan  have  shown  the  main  cause  of  these  actions.  Under 
the  influence  of  certain  micro-organisms,  the  albuminous  matters 
undergo  rapid  decomposition,  producing  a  nitrogenous  body  which 
has  been  identified  as  cliazobenzene.  Vaughan  originally  called 
this  body  tyrotoxicon  (cheese  poison).  It  is  highly  poisonous, 
but  also  very  unstable.  It  is  produced  early  in  the  decay  of  the 
albuminous  articles,  and  is  decomposed  subsequently.  We  can 
therefore  understand  why  articles  of  food  may  be  less  irritating 


932  MEDICAL   DIAGNOSIS. 

when  docidcdly  decomposed  than  wlien  decomposition  has  just  set 
in.  Besides  the  signs  of  g-astro-intestinal  irritation,  vertigo,  liead- 
ache,  marked  anxiety,  and  nuiseular  weakness  have  been  noticed 
among  the  effects  of  these  ptomaines. 

The  vegetal )k^  irritants  are  mainly  articles  commonly  used  as 
purgatives.  Thus,  clatcrinm,  (docs,  eoloci/idJt,  and  colchicuvi  have 
all  proved  fatal  when  taken  too  freely.  The  symptoms  do  not 
differ  materially  from  those  caused  by  other  poisons  of  this  class. 
Tobacco  and  lobelia  are  powerful  local  excitants,  occasioning  emesis 
and  purging,  with  a  speedy  collapse  of  the  system.  The  former, 
when  the  nicotine  produces  acute  symptoms  of  poisoning,  gives 
rise  also  to  salivation,  cold  sweats,  slow  pulse,  colicky  pains,  and 
at  times  convulsions.  Savin  not  only  produces  inflammation  of 
the  alimentary  canal,  but  is  apt  also  to  give  rise  to  strangury; 
it  is  most  frequently  resorted  to  with  the  view  of  bringing  on 
abortion.  Ergot  is  also  used  for  the  same  purpose;  the  most 
striking  symptoms  of  acute  ergot  poisoning  are  colic,  vomiting, 
diarrhoea,  increased  salivation,  retardation  and  weakening  of 
pulse,  muscular  weakness,  and,  in  severe  instances,  stupor.  The 
poisoning  rarely  ends  fatally. 

Poisonous  fungi,  such  as  the  fly  fungus,  which  are  eaten  by  mis- 
take for  muslirooms,  produce  violent  symptoms  of  irritant  poison- 
ing attended  with  other  phenomena.  The  poisonous  agent  in  the 
fly  fungus  is  muscarine,  and  it  gives  rise  to  vomiting,  violent  colic, 
and  diarrhoea,  besides  slowing  of  the  pulse  and  the  breatliing,  and 
violent  excitement  followed  by  stupor  and  somnolency.  The  case 
generally  lasts  two  or  three  days,  and  may  then  end  in  recovery 
or  in  collapse;  but  it  may  terminate  fatally  in  six  or  seven  hours, 
heemoglobinuria  being  among  the  symptoms.  Finding  the  fungi 
in  the  vomited  matter  or  in  the  stools  greatly  facilitates  the  diag- 
nosis. Other  poisonous  fungi  produce  much  the  same  symj)toms; 
and  even  the  usually-eaten  and  innocuous  kinds  of  mushrooms 
may,  if  at  all  spoiled,  or  in  certain  individuals,  or  when  eaten 
raw,  occasion  similar  symptoms. 

Narcotic  Poisoning. — The  symptoms  of  narcotic  poisoning 
vary  more,  according  to  the  special  article  taken,  than  those  caused 
by  irritants.  Narcotic  poisons  affect  chiefly  the  nervous  system 
and  the  circulation.  Many  of  them  produce  phenomena  like 
apoplexy  and  intoxication,  from  which  they  need  to  be  carefully 


POISONS   AND    PARASITES.  933 

distinguished.  Narcotic  poisoning'  i,s,  for  the  most  part,  of  the 
acute  form. 

Opium  is  by  far  the  most  important  of  narcotic  poisons.  It 
induces  giddiness,  stupor,  and  lethargic  sleep,  from  which,  how- 
ever, the  patient  can  at  first  be  roused,  if  sharply  spoken  to. 
Subsequently  this  sleep  deepens  into  coma  and  cannot  be  broken  ; 
the  skin  is  relaxed  and  perspiring ;  the  face  is  usually  pale ;  the 
pupils  are  contracted  and  insensible  to  light;  erections  of  the  penis 
are  common.  A  more  or  less  evident  odor  of  opium  may  often  be 
perceived  about  the  person  or  on  the  breath.  No  distinction  can 
be  drawn  between  the  effects  of  different  forms  of  this  poison :  the 
stronger  the  preparation,  however,  the  more  marked  and  the  more 
rapid  will  be  the  progress  of  the  case.  Morphine,  codeine,  nar- 
cotine,  and  the  other  alkaloids  give  rise  to  similar  symptoms, 
but  the  smell  of  opium  is  absent ;  convulsions  are  most  likely  to 
occur  from  narcotine,  papaverine,  and  thebaine. 

The  diagnosis  of  opium  poisoning  from  apoplexy  and  from  the 
coma  of  urcemia  has  been  discussed  in  a  former  chapter.  We  may 
merely  recall  that  the  contracted  pupil  caused  by  opium  is  of  very 
great  significance,  and  does  not,  with  the  exceptions  there  referred 
to,  exist  in  the  other  states.  Moreover,  the  coma  of  apoplexy  is 
at  once  developed ;  while  in  narcotic  poisoning  it  is  not  sudden, 
but  is  preceded  by  drowsiness  or  stupor,  M^iich  gradually  passes 
into  coma.  These  phenomena  occur  also  in  the  same  sequence 
in  uraemia ;  but  they  are  even  slower  in  their  progress,  and  are 
frequently  associated  with  convulsions  and  with  markedly  albu- 
minous urine  and  dropsy.  » 

From  acute  alcoholism  we  discriminate  opium  poisoning  chiefly 
by  the  absence  of  the  alcoholic  odor,  the  slow  respiration,  and  the 
presence  of  morphine  in  the  urine.  The  characteristic  smell  of 
chloroform,  the  great  pallor  of  the  countenance,  the  complete  and 
speedy  collapse,  and  the  absence  of  contracted  pupils  distinguish 
chloroform  poisoning  from  opium  poisoning.  It  is  the  same  with 
ether.  Poisoning  by  chloroform  and  by  ether  is  mostly  encoun- 
tered during  surgical  operations. 

Chloral,  in  excessive  doses,  produces  heavy  sleep,  with  con- 
tracted pupils ;  but  they  dilate  on  awaking.*     There  is  some  re- 

*  Taylor,  On  Poisons,  3d  edit.,  1875. 


934  MEDICAL    DIAGNOSIS. 

ductioii  of  tcniporaturc,  with  rapid  pulse,  o-idJiness,  inability  to 
walk  straight,  double  vision,  and  headaehe,  in  eases  in  wliieh 
consciousness,  sensibility,  and  muscular  ])o\ver  have  not  been 
entirely  sus})ended  by  the  dru<i-.  AVeak  action  of  the  heart  is 
another  of  the  dangers  of  chh)ral  poisoning,  and  I  have  known 
a  dilated  heart  almost  paralyzed  even  by  small  doses.  In  some 
instances  a  stage  of  excitement  like  alcoholic  intoxication  pre- 
cedes the  narcotism.     The  urine  may  or  may  not  contain  sugar.* 

Benzene,  when  taken  internally,  occasions  noises  in  the  head, 
muscular  tremor  and  twitchings,  and  deep  sleep ;  but  the  narcotic 
depression  ends  in  recovery. 

Alcohol,  if  taken  in  large  quantities  and  not  much  diluted,  gives 
rise  to  symptoms  like  those  caused  by  opium.  The  eye  is  in- 
jected and  the  seat  of  ecchymosis ;  the  pupils  are,  as  a  rule,  dilated 
and  very  sluggish  ;  the  breathing  is  irregular  and  stertorous  ;  the 
temperature  lowered  ;  the  insensibility  may  alternate  with  convul- 
sions ;  the  breath  has  a  strong  smell  of  alcohol  or  may  be  quite 
free  from  spirituous  odor.  This  absence  of  odor  of  the  breath, 
although  not  usual,  may  give  rise  to  a  confusion  between  alcoholic 
poisoning  and  apoplexy,  and  the  discrimination  of  these  condi- 
tions must  then  depend  in  some  measure  upon  evidence  furnished 
by  the  history  of  the  occurrence  of  the  insensibility,  and  by  the 
presence  or  absence  of  palsy. 

Alcohol  may  readily  be  detected  in  the  urine.  Woodbury's f 
modiiication  of  Ainstie's  test  is  very  convenient.  Into  a  tube 
containing  a  gramme  of  sulphuric  acid  (which  should  be  colorless 
or  nearly  so)  twice  as  mi>ch  of  the  urine  to  be  tested  is  poured. 
A  small  crystal  of  bichromate  of  potassium  is  then  dropped  in, 
and  the  liquid  slowly  mixed  by  rotating  the  test-tube.  If  alcohol 
be  present  in  proportion  as  large  as  two  or  three  parts  per  thou- 
sand, a  permanent  green  discoloration  results ;  if  there  be  less 
than  this,  the  liquid  will  remain  of  ruby  color.  Chloral  in  the 
urine  does  not  produce  the  peculiar  reaction. 

Belladonna,  or  its  active  principle,  atropine,  and  hi/oscyamus 
produce  more  marked  excitement  of  the  brain  than  opium  does, 


*  See  a  case  of  mine  recorded  in  a  Clinical  Lecture  on  Chloral  Poisoning, 
Phila.  Med.  Times,  March,  1883. 
t  Ibid. 


poiso:ns  and  tarasites.  935 

causing  delirium  of  active  kind,  perhaps  wiUi  convulsions.  The 
pupils  are  greatly  dilated,  and  vision  is  singidarly  deranged  ;  there 
is  intense  thirst,  with  great  dryness,  redness,  spasm,  and  l)iin)ing 
in  the  throat ;  the  breathing  is  rapid,  thus  differing  from  ai)0- 
plectic  conditions.  The  temperature  is  always  lowered;  tiie  pulse 
becomes  quick  and  compressible ;  a  scarlet  efflorescence  may 
happen.  The  surest  test  of  poisoning  by  atropine  is  to  take 
some  of  the  urine  passed,  and  with  it  to  dilate  the  pupil  in  the 
eye  of  a  cat. 

Gonium  occasions  stupor,  paralyzes  the  muscular  system,  and 
dilates  the  pupils ;  there  is  dyspnoea,  while  the  heart,  though 
rendered  slower,  is  not  much  affected.  Convulsions  may  come 
on.  These  help  to  distinguish  conium  poisoning  from  curare 
poisoning,  which  it  much  resembles.  In  the  latter,  however,  the 
palsy  is  greater. 

Carbolic  acid,  if  taken  in  poisonous  doses,  produces  rapidly 
dangerous  symptoms,  which  in  bad  cases  terminate  in  death  in 
a  few  hours.  Vomiting,  slow  pulse,  noisy  breathing,  loss  of 
consciousness,  deepening  into  profound  coma,  abolition  of  reflex 
movements,  cool  skin,  suppression  of  urine,  are  the  main  symp- 
toms. When  the  urine  is  obtained,  it  is  of  dark -green  or  black 
color ;  this  and  the  odor  of  carbolic  acid  about  the  patient  are 
very  significant  features.  The  discolored  urine  is  apt  to  contain 
blood-corpuscles,  casts,  epithelium,  and  tube-casts. 

Aniline  poisoning  is  met  with  among  the  workers  in  factories 
in  which  the  aniline  colors  are  made.  It  is  the  breathing  of  the 
aniline  vapor,  esj^ecially,  which  occasions  the  toxic  effect.  Ver- 
tigo, headache,  a  sense  of  suifocation,  vomiting,  aneesthesia,  pain 
in  the  extremities,  somnolency,  and  a  dark  cyanotic  discoloration 
of  the  ears,  the  nails,  and  the  mucous  membrane  of  the  nose,  have 
been  especially  noticed. 

Hydrocyanic  or  prussic  acid  usually  leads  to  convulsive  con- 
tractions of  the  muscles  of  the  limbs  and  trunk,  and  destroys  life 
by  stopping  the  circulation  and  the  respiration.  Sometimes  the 
odor  of  the  acid,  resembling  that  of  bitter  almonds,  is  percepti- 
ble in  the  breath  ;  but  too  much  reliance  must  not  be  placed 
upon  this  point.  Unfortunately,  the  diagnosis  of  this  poison  has 
generally  to  be  made  after  death,  for  medico-legal  purposes. 

The  gases  arising  from  burning  coal,  and  the  fumes  of  charcoal, 


936  MEDICAL    DIAGNOSIS. 

may  cause  death  by  aspliyxia;  and  a  knowledge  of  this  fact  has, 
particularly  in  France,  led  to  many  suicides.  In  those  eases  in 
which  the  asphyxia  has  not  a  fatal  termination,  yet  has  been 
decided,  disorders  in  the  peripheral  nerves  may  manifest  them- 
selves, either  by  the  signs  of  neuritis,  or  by  pain  and  swelling 
simulating  a  phlegmon,  or  by  vesicular  eruptions  in  the  course  of 
an  affected  vasomotor  nerve.  The  peripheral  disturbances  may 
appear  immediately,  or  not  imtil  after  some  days.  The  signs  of 
disorder  of  the  vaso-motor  nerves  do  not  last  long;  those  of  the 
motor  or  sensitive  nerves  have  a  longer  duration  ;  the  complaint 
induced  may  be  incurable,  extending  from  the  centre  to  tlie  pe- 
riphery, or  in  the  reverse  direction  ;  or,  lastly,  the  affection  may 
cause  an  acute  ascending  paralysis.* 

The  poisonous  action  in  these  cases  is  due  largely  to  carbon  mon- 
oxide (carbonic  oxide),  a  gas  which  has  a  strong  affinity  for  hserao- 
globin,  and  suspends  the  oxygen -absorbing  function  of  the  blood, 
thus  establishing  a  chemical  asphyxia.  The  gas,  being  non-irri- 
tating, may  be  inhaled  without  exciting  immediate  suspicion. 
The  so-called  water-gas  contains  large  amounts  of  carbon  mon- 
oxide. Experiment  has  sho^\•n  that  such  gas  is  much  more  dan- 
gerous when  inhaled  than  the  ordinary  illuminating  gas,  which 
consists  almost  entirely  of  compounds  of  carbon  and  hydrogen. 

Aniipyrin  given  in  large  doses  may  produce  extreme  lowering 
of  the  temperature,  and  collapse.  Cyanosis,  frequency  of  respira- 
tion and  of  pulse,  dysi^noea,  a  feeling  of  extreme  heat  over  the 
body,  and  an  erythematous,  urticarial,  or  measly  eruption,  have 
also  been  noticed.  In  one  instance  reported,  the  use  of  the  drug 
led  to  the  formation  of  membranes  in  the  mouth  and  to  symp- 
toms of  laryngeal  spasm,  which  ^^^as  not  the  case  when  jDhenacetin, 
antifebrin,  or  exalgin  \yas  substitutecl.f 

Petroleum  taken  in  excessive  cpiantities  produces  giddmess, 
faintness,  and  palpitation,  with  tonic  and  clonic  convulsions,  con- 
tracted pupils,  hot  skin,  and  slow  pulse  ;  it  does  not  occasion  either 
stupor  or  vomiting ;  the  urine  has  an  aromatic  odor.  Recovery 
is  the  rule. 

Nitro-glycerin   occasions  a  throbbing   headache   increased   by 


*  Leudet,  Arch.  Gen.  de  Med.,  May,  1865. 

f  Salinger,  Amer.  .Jouru.  Med.  Sei.,  May,  1890. 


POISONS   AND   PARASITES.  937 

motion,  mental  confiisiou,  fliishhi<^  of  tlie  face,  pulsations  all  over 
the  body,  arterial  relaxation,  and  collapse. 

Following  these  poisons,  which  are  in  tlie  main  narcotic;  poisons 
or  belong  to  the  group  of  jjoisonous  carbon  compounds,  we  shall 
examine  some  forms  of  acute  poisoning  produced  by  certain 
powerful  vegetable  poisons. 

Aconite  has  a  strongly  sedative  influence  upon  the  action  of  tlie 
heart,  brain,  and  spinal  cord,  as  well  as  an  irritant  action  upon 
the  alimentary  canal ;  slow  pulse,  giddiness,  delirium,  numl)ness, 
and  tingling  of  the  skin,  loss  of  power  in  the  legs,  with  formica- 
tion, tingling  of  the  tongue,  vomiting,  and  purging,  are  followed 
by  syncope  and  death. 

Digitalis  causes  dilatation  of  the  pupil,  generally  with  vomiting, 
often  with  purging  and  with  headache,  giddiness,  and  suppression 
of  urine ;  its  chief,  effect,  however,  is  upon  the  pulse,  which  is 
strikingly  lessened  both  in  frequency  and  in  force,  and  becomes 
irregular ;  the  action  of  the  heart,  too,  becomes  weak,  and  blood- 
pressure  is  diminished.  The  skin  is  cold,  pale,  and  covered  with 
sweat ;  the  mind  is  generally  clear,  though  there  is  great  lassi- 
tude, with  muscular  debility,  a  tendency  to  sleep,  and  at  times 
convulsions.  The  action  of  the  poison  generally  extends  over 
days.  Veratrum  virlde  resembles  digitalis  in  its  action.  It 
markedly  reduces  the  pulse,  and  gives  rise  to  vomiting,  to  great 
prostration,  and  to  irregular  breathing.  The  temperature  is  much 
lowered. 

Calabar  bean  acts  as  a  direct  sedative  to  the  spinal  marrow, 
particularly  to  the  medulla,  and  produces  great  muscular  debility 
or  relaxation,  or  even  paralysis,  extending  to  the  heart  and  respi- 
ratory muscles.  The  mental  faculties  remain  unaffected,  and  in 
this  its  action  differs  from  that  of  the  cerebral  sedatives.  It  is, 
however,  irritant  to  the  alimentary  canal,  causing  vomiting  or 
purging,  a  peculiar  epigastric  sensation  is  generally  experienced, 
and  increased  salivation  is  met  with.  Calabar  bean  contracts  the 
pupil  and  also  the  ciliary  muscle,  thus  making  the  eye  myopic. 
The  condition  of  the  eye  is  the  main  diagnostic  sign  that  dis- 
tinguishes poisoning  by  calabar  bean  from  poisoning  by  ctirare  or 
by  conium. 

Strychnine  and  brucine,  the  active  principles  of  nux  vomica  and 
of  several  allied  plants,  give  rise  to  phenomena  strongly  resem- 


938  MEDICAL   DIAGNOSIS. 

bling-  those  of  tchtnus.  A  very  short  time,  liOAvever, — from  a  few 
minutes  to  an  hour  or  two, — will  determine  the  issue  of  a  case  of 
poisoning ;  while  tetanus  may  run  a  course  of  several  weeks.  The 
first  symptoms  of  strychnine  ])oisoning  are  apt  to  be  a  sense  of 
suffocation  and  dyspna^a,  followed  by  spasms  of  the  respiratory 
muscles,  by  starting  and  twitching  and  rigidity  of  the  arms  and 
legs,  especially  of  the  extensor  muscles,  but  not  by  lock-jaw  ;  teta- 
nus, on  the  otlier  hand,  comes  on  with  setting  or  locking  of  the 
jaws,  and  the  limbs  are  not  at  first  affected  with  spasms  ;  indeed, 
the  arms  remain  throughout  nearly  free  from  them,  and  the 
paroxysms  of  spasm  do  not  follow  one  another  so  rapidly  as  in 
strychnine  poisoning,  and  are  of  shorter  duration.  Again,  idio- 
pathic tetanus  is  extremely  rare  ;  almost  always  there  has  been  some 
wound  or  injury  as  a  proximate  cause  of  the  malady.  But  we 
need  not  pursue  these  points  of  diagnosis  further :  they  have  been 
already  mentioned  in  connection  with  tetanus.  From  epilepsy 
strychnine  poisoning  differs  by  the  unimpaired  consciousness;  from 
hydrophobia,  by  the  absence  of  spasm  of  the  oesophagus  and  of 
the  terrible  dysphagia. 

Picvotoxin  also  produces  convulsions  which  may  be  mistaken  for 
those  caused  by  strychnine.  But  they  are  not  of  a  reflex  nature, 
and  reflex  spasms  are  not  induced.  The  breathing  is  rapid  ;  the 
contraction  of  the  heart  is  retarded  ;  there  are  often  somnolence 
and  muscular  debility.     A  scarlatinal  eruption  has  been  noticed. 

Chronic  Poisoning. 

When  the  patient  has  been  subjected  to  the  continuous  action  of 
a  noxious  substance,  the  case  is  said  to  be  one  of  chronic  or  slow 
poisoning.  Any  of  the  irritant  poisons,  given  in  small  and  re- 
peated doses,  will  keep  up  a  morbid  condition  of  the  stomach  and 
bowels  much  like  ordinary  chronic  inflammation. 

The  narcotics,  taken  in  the  same  manner,  act  upon  the  vaso- 
motor nerves  and  the  cerebro-spinal  system,  and  through  this 
upon  the  alimentary  canal,  so  deranging  digestion  and  nutrition 
as  even  indirectly  to  cause  death.  Opiniii  is  the  most  important 
of  the  articles  thus  used  ;  it  is  often  administered  to  infants  for 
the  purpose  of  quieting  their  cries,  and  the  frequent  repetition 
of  the  dose  induces  a  series  of  phenomena  closely  allied  to  those 


POISONS    AND    PARASITES.  039 

observed  in  the  adult.  "With  tlic  effects,  on  the  mind,  of  opium 
taken  persistently  for  the  sake  of  intoxication,  the  reading  world 
is  familiar  through  the  published  experiences  of  De  Quincey  and 
of  Coleridge. 

The  habit  is  here  and  in  Europe  generally  acquired  only  Ijy 
persons  who  have  begun  the  practice  for  the  relief  of  some  painful 
affection  ;  in  the  East,  opium  is  used  much  more  commonly,  and, 
in  many  Oriental  countries,  to  smoke  it  is  a  favorite  amusement. 
Those  who  employ  it  constantly  are  pale,  or  have  a  sallow,  hag- 
gard countenance  and  a  dull  eye.  They  lose  their  power  of  will 
and  their  energy,  and  are  troubled  by  loss  of  appetite,  giddiness, 
anomalous  neuralgic  pains,  sleeplessness,  and  low  spirits,  which 
they  remove  by  resorting  to  the  opiate.  Though,  in  spite  of  the 
pernicious  custom,  the  general  health  may  remain  for  many  years 
good,  yet  sooner  or  later  it  gives  way,  and  the  opium-eater  dies 
worn  out ;  or  death  may  be  the  consequence  of  disease  of  the  liver, 
of  palsy,  or  of  inveterate  diarrhoea,  produced  by  long  addiction 
to  the  vice.  Persons  who  consume  large  quantities  of  opium  are 
apt  to  have,  from  time  to  time,  attacks  of  extreme  nervous  pros- 
tration, attended,  perhaps,  with  violent  headache,  and  requiring 
free  stimulation  for  their  relief.  The  employment  of  morphine 
liypodermically  has  become  an  alarmingly  frequent  form  of  the 
opium  habit,  especially  among  members  of  the  medical  profes- 
sion. Besides  the  general  symptoms  of  chronic  opium  poisoning, 
we  may  have  extensive  ulcers  and  other  local  signs  of  skin  irrita- 
tion to  deal  with. 

Ether  and  chloroform,,  habitually  made  use  of,  also  cause  serious 
disturbance  of  the  nervous  system ;  and  so  does  alcohol.  The 
abuse  of  spirituous  liquors  gives  rise  to  a  disorder  of  the  mental, 
motor,  and  sensory  functions,  producing  sleeplessness,  headache, 
giddiness,  hallucinations,  imbecility,  anaesthesia,  disordered  vision, 
and  palsies.  Chronic  alcoholism  also  occasions  a  sensation  of 
choking,  a  diminished  vitality,  a  persistent  catarrh  of  the  gastro- 
intestinal membrane,  a  tendency  to  fatty  degeneration,  especially 
of  the  liver  and  kidneys ;  in  short,  the  symptoms  often  met  with 
in  drunkards,  and  constituting  the  state  described  as  chronic  alco- 
holism. Chronic  alcoholism  in  the  parent  may  produce  epilepsy 
in  the  child. 

Chloral  has  proved,  like  opium  and  like  chloroform,  a  very 


940  MEDICAL    DIAGNOSIS. 

flist'inating  drug-  to  manv.  The  chief  symptoms  of  ehronie  chloral 
poisoning  are  digestive  disorders,  irregular  hreatiiing,  impairment 
of  intellig'enee  and  of  memory,  persistent  drowsiness,  almost 
stupor,  striking  enfeeblement  of  Avill,  want  of  power  in  the  legs 
amounting  at  times  to  paralysis,  and  occasional  tremor.  Defective 
co-ordination  with  marked  ataxic  symptoms,  similar  to  those  of 
locomotor  ataxia,  and  loss  of  knee-jerk,  occur  from  the  habit  of 
taking  chloral.*  I  have  known  delirium  tremens  to  follow  its 
use,  when  large  quantities  of  it  had  been  taken  and  the  medicine 
stop[)ed.  Feeble,  irregular  action  of  the  heart,  and  sweating,  I 
have  also  ibund  among  the  symptoms  of  chloral  poisoning.  An 
erythematous  inflammation  of  the  skin  of  the  fingers,  with  des- 
quamation and  ulceration  around  the  borders  of  the  nails,  has 
been  pointed  out  as  a  result  ;t  and  various  forms  of  eruption, 
such  as  urticaria,  lichen,  and  purpurous  spots,  as  well  as  bed-sores, 
have  been  observed  after  its  prolonged  use. 

Paraldehyde  is  abused  like  chloral  and  morphine.  It  gives 
rise,  M"hen  taken  habitually,  to  gastric  disorder,  diarrhcea,  sleep- 
lessness, feeble  circulation,  sweating,  and  delirium  tremens. 

Tobacco  used  in  excess  gives  rise  to  tremors,  to  giddiness,  to 
emaciation,  to  impaired  digestion,  and  to  intermittence  in  the 
pulse,  with  irregular  cardiac  action  and  palpitations,  which  may 
become  very  annoying  and  originate  the  belief  of  an  oi'ganic  dis- 
ease of  the  heart.  Like  the  persistent  abuse  of  alcoholic  drinks, 
tobacco  may  occasion  amaurosis ;  and  it  is  also  affirmed  that  an 
insidious,  obstinate  form  of  otitis  is  developed  in  inveterate 
smokers,  and  is  attended  with  very  minute  granulations  of  the 
pharynx,  nasal  fossae,  tubes,  and  middle  ear.|  When  taken  in 
large  quantities  by  those  previously  unaccustomed  to  it,  tobacco 
produces  colic,  diarrhoea,  weakness,  sleeplessness,  dull  hearing, 
vomiting,  difficulty  in  breathing,  cold  sweats,  feeble  action  of  the 
heart,  and  will  even  cause  collapse  and  death.  The  peculiar  odor 
of  tobacco  may  assist  us  in  the  diagnosis  of  tobacco  poisoning ; 
but  it  must  be  remembered  that  this  may  attend  other  morbid 
states  in  those  who  use  tobacco  largel}'. 


*  J.  C.  Wilson,  article  "  Opium  Habit  and  Kindred  Affections,"  System  of 
Practical  Medicine  by  American  Authors,  vol.  v. 
I  Smith,  Lancet,  vol.  ii.,  1871. 
j  Triquet,  Le  Briert. 


POISOXS   AND    PARASITES.  941 

Ergot  long  continued,  particularly  when  taken  contained  in 
impure  flour,  gives  rise  to  the  weil-(.'haracterized  disease,  chronic 
ergotism.  This  appears  mainly  in  two  forms :  the  first  is  marked 
by  convulsions  with  disturbance  of  sensation  ;  the  second  by  gan- 
grene; both  are  apt  to  show  themselves  in  epidemics.  In  the 
convulsive  form  there  is  at  first  formication,  which  lasts,  wliether 
attended  vvith  anaesthesia  or  not,  throughout  the  whole  ilhiess. 
Soon  muscular  twitchings  and  cramps  followed  by  painful  con- 
tractions happen,  and  the  convulsions  may  become  very  general. 
These  spasms  especially  affect  the  flexors  of  the  arm,  and,  unlike 
those  of  strychnine,  they  are  not  reflex  spasms.  There  is  no  fever ; 
the  circulation  is  slow  and  feeble  ;  the  appetite  is  insatiable ;  we 
find  nausea,  vomiting,  and  diarrhoea.  The  disease  generally  lasts 
one  or  two  months.  In  severe  cases  delirium  occurs  as  a  precursor 
to  death.  In  gangrenous  ergotism  the  same  symptoms  happen  ; 
but  in  addition  we  meet  with  gangrene  without  fever  or  signs  of 
inflammation.  The  gangrene  may  be  in  the  extremities  or  in  the 
face.  Where  ergot  is  being  taken  in  diabetes,  the  gangrene  results 
from  the  malady,  not  from  the  drug. 

Let  us  now  examine  some  of  the  features  of  slow  poisoning  by 
the  metals. 

Mercury,  in  any  of  its  preparations,  may  lead  to  chronic  poison- 
ing. The  mouth  is  inflamed,  the  gums  are  sore  and  swollen,  the 
salivary  glands  act  inordinately,  and  the  breath  is  very  offensive. 
Colicky  pains,  and  sometimes  diarrhoea,  occur.  Tremors  of  the 
limbs  when  any  motion  is  attempted  are  particularly  frequent  in 
cases  where  the  poison  has  been  inhaled  in  the  form  of  vapor ; 
they  come  on  by  degrees,  and  are  associated  with  loss  of  power  of 
locomotion  and  with  digestive  disturbances.  The  tremors  may 
be  incessant  and  the  movements  involuntary,  like  those  of  chorea, 
and  so  rapid  as  to  prevent  the  patient  from  obtaining  rest  at 
nia;ht.*     In  some  cases  an  eczematous  affection  is  observed. 

Poisoning  by  mercury  is  generally  the  result  of  the  exposure  to 
its  action  incidental  to  certain  occupations,  such  as  glass-plating, 
gilding,  and  working  in  quicksilver-mines. 

*  As  in  a  case  reported  by  Taylor,  in  which  the  patient  died  from  the 
effects  of  the  poison,  without,  however,  having  presented  salivation  or  mer- 
curial fetor  of  the  breath,  or  a  blue  line  on  the  gums.  Guy's  Hospital  Reports, 
3d  Series,  vol.  x. 


942  MEDICAL  DiAoxosrs. 

Lead  poisoning  is  by  no  means  unconniion  among  painters, 
plumbers,  type-setters,  and  other  workers  in  lead.  Sometimes  it 
may  be  caused  by  accidental  circumstances,  as  when  the  patient 
has  drunk  water  passed  through  leaden  pipes,  or  taken  snuff  which 
has  been  impregnated  with  lead  for  the  purpose  of  coloring  it. 
Poisonous  properties  are  also  acquired  by  snuff  wrapped  in  lead- 
foil  ;  and  lead  poisoning  has  beeii  observed  after  the  use  of  cos- 
metics ;  and  among  those  engaged  in  the  manufacture  of  lucifer 
matches,  of  brushes,  of  lace,  or  working  in  glass  enamel  or  glass 
powder;'^  and  in  consequence  of  food  adulteration,  especially  of 
the  use  of  lead  chromate  to  color  cakes. f 

In  such  cases,  the  physician  may  have  to  depend  entirely  upon 
a  correct  appreciation  of  the  symptoms  for  the  diagnosis.  Pain 
and  uneasiness  in  the  course  of  the  colon,  constipation,  loss  of 
appetite,  ancemia,  weakness,  mental  depression,  and  emaciation  are 
the  earlier  signs.  A  metallic  taste  is  perceived ;  the  breath  is 
fetid,  the  tongue  pale  and  furred  •  the  gums  are  edged  with  a 
narrow  blue  line  of  sulphide  of  lead,  deposited  mainly  outside 
loops  of  blood-vessels.  Colicky  pains  are  felt  from  time  to  time, 
and  a  severe  and  long-continued  attack  of  colic  may  form  the 
culmination  of  the  disease.  The  muscles  atrophy ;  electro-mus- 
cular contractility  to  the  faradaic  current  is  greatly  diminished,  to 
the  galvanic  current  it  is  frequently  unaltered  or  increiised ;  the 
sensibility  of  the  skin  is  but  little  affected.  Occasionally  wrist- 
drop or  paralysis  of  the  extensor  muscles  of  the  forearms,  the 
Avell-known  phenomenon  of  lead  poisoning,  occurs  among  the 
first  symptoms;  but  it  is  moi'e  generally  preceded  by  one  or  more 
attacks  of  colic.  The  right  arm  mostly  suffers  first.  We  also 
find  at  times  lesions  of  the  tendons  in  saturnine  palsy. |  Yet  as 
regards  this  palsy  we  must  bear  in  mind  that  a  paralysis  of  the 
extensors  occurs  which  is  not  due  to  lead.§ 

Another  manifestation  of  lead  poisoning  is  found  in  the  severe 
pains  in  the  joints  and  the  neighboring  muscles.  These  pains  have 
violent  exacerbations,  and  may  be  associated  with  cramps  of  the 

*  Lacharrierc,  Arch.  Gen.  de  Med.,  Deo.  1859. 

t  Stewart,  Clinical  Analysis  of  Sixty-Four  Case.*  of   Poisoning  by  Lead 
Chromate,  ^ledicul  News,  Dec.  31,  1887,  and  ib.,  Jan.  2G,  1889. 
J  Medical  Times  and  Gazette,  May,  1868. 
5  St.  George's  Hospital  Reports,  18G8,  p.  8G. 


POISONS   AND    PA TIA SITES.  94o 

painful  muscles.  They  are  most  common  in  the  lower  extremity, 
especially  over  and  near  the  knee-joints.  There  are  no  signs  of 
inflammation  of  the  affected  joints  and  muscles;  pressure  tends 
to  relieve  the  pains. 

Sometimes,  in  cases  of  saturnine  poisoning,  there  is  evidence  of 
grave  cerebral  disorder :  epileptiform  convulsions,  attacks  resem- 
bling apoplexy,  or  general  tremors  and  extended  paralysis  of  the 
muscles,  with  acute  delirium,  inequality  of  the  pupil,  optic  neu- 
ritis, retinal  hemorrhages,  loss  of  sight,  and  other  signs  of  nervous 
disturbance,  are  noticed.  Of  course  the  diagnosis,  under  these 
circumstances,  will  be  materially  assisted  by  an  accurate  knowl- 
edge of  the  previous  history  of  the  patient  as  regards  exposure 
to  the  action  of  the  poison.  The  tremors  are,  like  those  caused 
by  mercmy,  peculiar  in  ceasing  when  the  limbs  are  supported  or 
at  rest ;  they  are  increased  by  movement.  There  may  be  tremor 
in  the  muscles  of  the  face,  which,  however,  are  not  affected  by 
paralysis.  Another  result  of  lead  poisoning  is  that  it  leads  to 
granular  degeneration  of  the  kidneys.  This  is  apt,  again,  to 
coexist  with  a  gouty  condition,  which,  as  Garrod  has  shown,  is 
one  of  the  results  of  the  absorption  of  lead.  But  the  kidney 
affection  may  be  found  whether  or  not  the  joints  are  markedly 
affected.  Lancereaux  *  has  attributed  most  of  the  cerebral  symp- 
toms and  the  dyspnoea  that  may  be  met  with  to  the  diseased 
condition  of  the  kidneys,  which  may,  however,  exist  without 
albuminous  urine. 

In  instances  in  which  the  symptoms  of  lead  poisoning  are  ob- 
scure or  conflicting,  wx  may  search  for  lead  in  the  urine.  The 
plan  of  Doremus,  which  consists  in  evaporating  the  urine  in  a 
porcelain  dish  with  nitrate  of  sodium,  and  adding  fuming  nitric 
acid,  then  distilled  water  and  sulphuretted  hydrogen,  is  very 
convenient. 

Copper  poisoning  gives  rise  to  dyspeptic  symptoms,  to  diuresis, 
to  loss  of  flesh,  to  lassitude  and  giddiness,  to  a  peculiar  greenish- 
blue  perspiration,  and  to  a  green  line  on  the  gums  and  teeth.  It 
is  said  that  workmen  in  copper  are  singularly  insusceptible  to 
cholera  or  choleraic  diarrhoea,t  and  that  woiuids  in  them  heal 

*  Arch.  Gen.  de  Med.,  Dec.  1881. 

f  Clapton,  Clinical  Society's  Transactions,  vol.  iii. 


944  MEDICAL   DIAGNOSIS. 

with  extraordinary  rai)idity.  Copper  appears  to  be  somewhat 
k^ss  liabU^  than  nierenry,  lead,  arsenie,  or  antimony  to  cause 
serious  elironic  jioisoning,  possibly  because  it  is  less  cumulative. 
Small  amounts  of  copper  are  frequently  jn-esent  in  the  liver  and 
brain  of  man  and  some  of  the  k)wer  animals,  also  in  some  articles 
of  food.  Dr.  Letfmann  informs  me  that,  in  the  examination  of 
viscera  from  the  cases  of  lead  poisoning  which  occurred  in  Phila- 
delphia, copper  in  minute  amounts  was  frec|uently  encountered, 
and  in  one  case,  that  of  a  child  four  years  of  age,  an  appreciable 
quantity  Avas  obtained  from  a  portion  of  the  liver. 

Ai'senic,  administered  in  small  doses  for  a  lengthened  period, 
produces  a  state  of  chronic  inflannnation  of  the  alimentary  canal. 
Conjunctivitis,  oedema  of  the  face  and  the  limbs,  in  some  instances 
associated  with  albuminous  urine,  irritability  of  the  stomach,  diar- 
rhosa,  sleeplessness,  increasing  weakness,  numbness,  formication, 
alterations  of  sensation,  and  even  paralysis,  mark  the  progress  of 
these  cases ;  the  hair  and  the  nails  occasionally  fall  out,  and  there 
is  much  frontal  headache.  Similar  effects  are  noticed  to  follow 
the  pernicious  habit  of  arsenic-eating,  and  will  be  also  encountered 
among  persons  employed  in  making  artificial  flowers  and  toys, 
in  dyeing  cloths,  in  manufacturing  and  hanging  green  wall- 
papers, or  in  the  sublimation  of  arsenical  ores ;  those,  too,  who 
live  in  rooms  hung  with  papers  containing  much  arsenic  have 
exhibited  the  influences  of  the  poison.*  Besides  the  phenomena 
of  internal  poisoning,  cutaneous  eruptions  occur  from  arsenic. 
The  extensors  of  the  hands  and  feet  are  especially  affected.  In 
some  instances,  said  to  be  not  uncommon  in  Rnssia,t  paralysis 
of  the  extremities,  with  muscular  atrophy,  happens.  Arsenical 
paralysis  may  have  mainly  the  symptoms  of  poliomyelitis,  as  I 
have  had  occasion  to  observe. j]  In  other  cases  there  are  severe 
darting  pains  in  the  arms  and  legs,  defective  cutaneous  sensibility, 
loss  of  knee-jerk,  and  the  appearances  of  locomotor  ataxia. §  The 
palsies  of  arsenical  poisoning  are  now  generally  thouglit  to  be 
due  to  peripheral  neuritis. 

*  .James  Putnam,  Anal\-sis  of  Twenty-Six  Cases,  Bost.  Med.  and  Surg. 
.Journ.,  March,  1889. 

t  ScoLjsubolt;  Arch,  de  Phys.,  SejDt.  1875. 
X  Phihi.  Mod.  Times,  March  and  July,  1881. 
^  Dana,  Brain,  vol.  ix. 


POISONS    AND    PARASITES.  945 

The  inhalation  of  the  fumes  of  zinc  gives  rise  to  a  i)eeuliar 
form  of  poisoning,  characterized  by  a  sense  of  weariiKiSS,  by  a  feel- 
ing of  tightness  in  the  chest,  and  by  attacks  of  shivering,  followed 
by  heat  of  skin  and  a  profuse  sweating-stage.  This  irregular 
form  of  ague  is  common  among  brass-founders.* 

Bisulphide  of  carbon  produces  toxical  effects  of  a  singular  char- 
acter, conspicuous  among  which  are  gastric  disturbances,  inordinate 
appetite,  loss  of  muscular  strength,  a  cachectic  condition,  a  feeling 
of  icy  coldness  in  the  lower  limbs,  severe  cramps  in  the  calves 
of  the  legs,  impotence,  and,  in  severe  cases,  amaurosis,  impaired 
hearing,  hallucinations,  loss  of  memory,  and  complete  perversion 
of  the  intellect.!  These  phenomena  are  met  with  among  workers 
in  india-rubber. 

Phosphorus  is  often  seen,  particularly  among  those  who  work 
in  lucifer-match  factories,  to  give  rise  to  serious  lesions.  When 
the  poisoning  is  caused  by  inhaling  the  vapor,  it  may  occasion, 
as  acute  phosphorus  poisoning  does,  alteration  of  the  composition 
of  the  blood,  a  hemorrhagic  diathesis,  a  fatty  degeneration  of 
several  organs,  as  well  as  of  the  voluntary  muscles,^  and  pepto- 
nuria. It  also  produces  chronic  bronchial  catarrh,  but  especially 
necrosis  of  the  jaw,  for  which  the  whole  lower  jaw  has  been  re- 
moved.§  The  disease  begins  in  carious  teeth,  and  may  extend 
to  the  cranial  bones.  Osteophytes  form  freely  in  the  aifected 
bones.  Phosphorus  taken  internally  in  doses  that  gradually  exert 
a  poisonous  effect  leads  to  chronic  inflammation  and  thickening  oi, 
the  stomach,  colicky  pains,  diarrhoea,  hectic  fever,  general  emacia- 
tion, falling  out  of  the  hair,  and  to  palsies,  which  are  generally 
the  precursors  of  a  fatal  termination. 

Animal  poisons. — These  may  give  rise  to  chronic  as  well  as  to 
acute  poisoning.  We  find,  for  instance,  syphilis,  gonorrhoea,  hy- 
drophobia, dissecting  wounds,  snake-bites,  acute  glanders,  and 
farcy, — all  disorders  exhibiting  the  effect  of  an  animal  virus. 
But  we  have  already  discussed  some  of  these  as  far  as  is  admis- 

*  Greenhow,  Med.-Chir.  Transact  ,  1862. 

t  Delpech,  Memoires  de  I'Academie  de  Medeoine,  1856 ;  and  Heurtaux, 
Kecueil  de  la  Societe  Medicale  d' Observation,  1860. 

I  Lancereaux,  L'Union  Medicale,  1863. 

§  Cases  of  Hunt  and  Boker,  Amer.  Journ.  Med.  Sci.,  April,  1865;  Wells, 
New  York  Med.  Journ.,  Jan.  1866  ;  Wegener,  Virchow's  Archiv,  Bd.  xl. 

60 


946  MEDICAL   DIAGNOSIS. 

sible  in  a  work  of  this  kind  ;  and  of  the  otiicrs  it  need  only  be 
siiid  that  the  antecedent  eironmstances  generally  place  the  diag- 
nosis beyond  a  doubt. 

Yet  there  are  a  few  illustrations  of  animal  poisons  and  their 
effects  which  must  here,  however  briefly,  be  mentioned. 

One  of  these  is  the  malignant  pustule,  or  anthrax,  a  terrible 
malady,  which  is  the  cause  of  many  deaths  on  the  Continent  of 
Europe,  and  which  is  identical  with  the  charbon  of  animals.  The 
disorder  is  also  prevalent  in  New  Mexico.*  It  is  communicated 
to  man  by  direct  inoculation  ;  or  by  means  of  the  skin  or  hair 
of  the  diseased  beast,  or  by  eating  its  flesh ;  or  by  insects  which, 
sucking  the  poison  from  the  sick  animal,  implant  it  on  the  skin  of 
man.  The  poison  produces  a  red  speck,  which  develops  into  a 
vesicle,  under  and  around  which  an  extremely  hard  spot  forms 
that  becomes  gangrenous.  The  surrounding  skin  inflames,  new 
vesicles  or  pustules  spring  up,  and  the  gangrene  spreads  rapidly, 
the  patient  speedily  sinking  ;  or  the  death  of  the  parts  is  arrested, 
and  separation  takes  place  between  the  living  and  the  gangrenous 
textures.  In  some  cases  it  is  attended  with  extended  oedematous 
swelling  and  infiltration  of  the  areolar  tissue  spreading  from  the 
anthrax  pimple.  It  is  remarkable  how  little  local  pain  attends 
the  grave  constitutional  disturbance,  and  the  signs  of  low,  irrita- 
tive fever.  The  disease  is  found  on  the  exposed  portions  of  the 
body,  as  on  the  neck  and  hands.  It  has  been  traced  by  Davaine 
to  the  presence  of  filiform  bacteria,  bacillus  anthracis.  The 
blood  swarms  with  these  bacilli ;  and,  as  Koch  has  proved,  they 
propagate  themselves  by  spores,  which  finally  grow  into  l)ac- 
teria.  The  researches  of  Pasteur  and  of  Koch  fully  confirm  the 
parasitic  view  of  the  origin  of  the  disease. 

Closely  connected  with  malignant  pustule  is  the  so-called  "  vool- 
sorter's  diseased'  The  wool  from  sheep  is  not  nearly  so  dan- 
gerous as  the  hair  from  the  goat,  the  alpaca,  and  the  camel.  The 
mohair  from  the  Lake  Van  district,  Asia  Minor,  is  the  most 
dangerous.  The  symptoms  may  be  those  of  malignant  pustule 
with  secondary  splenic  fever,  or  there  often  is  an  utter  absence 
of  either  external  or  internal  pustule. f     The   manifestations  of 


*  A.  H.  Smith,  Amer.  .Journ.  Med.  Sci.,  April,  1867. 
t  Bell,  Lancet,  June  12,  1880. 


POISONS    AND    PARASITES.  947 

the  disease  are  frequently  a  low  fever  with  secondary  abscesses, 
pyiiemic  symptoms,  and  plcuro-pncumonia.  The  complaint  is  a 
dangerous  one,  and  often  fatal ;  when  ending  in  recovery,  con- 
valescence is  slow. 

Another  disease  transmitted  from  infected  animals,  and  due,  it 
is  thought,  to  fungi,  is  the  so-called  actinomycosis  hominis,  de- 
scribed chiefly  by  Israel  *  and  by  Ponfick.f  The  disease  first  ap- 
pears in  the  lower  part  of  the  face,  in  the  shape  of  little  abscesses 
containing  vellowish  granules,  which  consist  of  fungi.  These 
vegetations  are  readily  detected  by  the  microscope.  The  disease 
spreads  to  the  ribs  and  vertebrae,  and  produces  great  destruction 
of  tissue ;  it  is  also  found  in  the  liver  and  the  lungs ;  there  are 
the  symptoms  of  pyaemia. 

The  foot  and  mouth  disease  is  an  aifection  from  which  especially 
children  suifer  who  have  drunk  the  milk  from  infected  cows.  The 
poison  produces  an  aphthous  stomatitis  with  digestive  disorder, 
and  frequently  also  a  vesicular  eruption  on  the  face  and  on  the 
lingers  and  hands,  which  gradually  dries  into  brownish  scales, 
and  at  times  a  similar  eruption  between  the  toes.  The  disorder 
is  not  a  serious  one. 

There  is  another  form  of  animal  poisoning  which  may  be  in 
this  connection  briefly  considered, — namely,  milk-sickness.  Now, 
its  phenomena  are  so  variously  described  by  writers  that  its 
characteristic  signs  are  difficult  to  define.  It  prevails  in  the 
southern  and  southwestern  portions  of  North  America,  and  is 
brought  on  by  drinking  the  milk  or  eating  the  flesh  of  cattle 
which  have  been  exposed  to  certain  influences  the  nature  of  which 
is  as  yet  unl^nown.  Gastritis  and  enteritis  seem  to  be  more  or 
less  blended  in  the  early  stage  of  this  disorder,  which  at  a  later 
period  is  said  strongly  to  resemble  typhus  fever.  The  symptoms 
more  especially  dwelt  upon  are  lassitude,  nausea  and  vomiting, 
Avith  a  sense  of  burning  at  the  epigastrium,  great  oppression, 
intense  thirst,  hot,  dry  skin,  obstinate  constipation,  and  obvious 
abdominal  pulsation.  If  at  all,  recovery  takes  place  very  tardily, 
the  tone  of  the  stomach  being  often  left  impaired  for  life. 

Other  forms  of  animal  poisons  originate  in  alkaloids  generated 


*  Virchow's  Archiv,  Bde.  Ixxxv.,  Ixxviii. 

f  Die  Actinomykose  des  Menschen,  Berlin,  1882. 


948  MEDICAL    DIAGNOSIS. 

during  decay.  The  poisoniug  bv  these  ptomoines  from  milk  and 
eggs  and  other  substances  has  ah'cady  been  mentioned.  Fre- 
quently the  ptomaine  poisoning  resembles  that  ot"  the  vegetable 
alkaloids,  such  as  of  morphine,  codeine,  and  veratrine. 

Besides  these  forms  of  animal  poisoning,  which  are  produced 
by  the  direct  contact  with  the  virus,  or  at  all  events  by  its  intro- 
duction into  the  system  through  the  stomach,  we  find  morbid 
states  occasioned  by  animal  poisons  which  arise  from  decomposing 
bodies  or  excretions,  or  from  the  crowding  of  many  together,  par- 
ticmlarly  of  those  of  uncleanly  habits,  or  of  the  wounded.  These 
poisons  reach  the  blood  for  the  most  part  by  the  lungs,  in  the 
shape  of  poisonous  cxlialatioTis.  They  are  very  depressing  in  their 
action,  may  lead  to  low  fevers,  or  to  septicaemia,  and  in  the  case 
of  the  wounded  to  pyasmia  and  to  hospital  gangrene.  Persistent 
nausea,  too,  and  a  lowei'ing  of  all  vital  energy  are  not  uncom- 
monly observed  in  those  who  breathe  continuously  the  foul  air 
under  the  circumstances  alluded  to, — as  in  hospitals  and  in  prisons 
in  which  thorough  cleanliness  is  not  enforced  and  due  regard  is 
not  paid  to  ventilation. 

In  some  persons  deleterious  emanations  from  the  human  body 
give  rise  to  a  form  of  toxsemia,  one  of  the  chief  features  of  which 
is  the  marked  anorexia  which  attends  the  great  debilitv.* 

The  exposure  to  animal  effluvia  may  also  excite  violent  diar- 
rhoea, or  even  symptoms  like  those  of  cholera,  certainly  like  those 
of  severe  attacks  of  cholera  morbus.  Of  the  occurrence  of  the 
former  we  have  an  illustration  in  the  dissecting-room  diarrhoea, 
which  is  usually  attended  with  very  fetid  discharges,  and  may  be 
accompanied  by  colicky  pains,  by  nausea  and  vomiting,  and  by 
headache.  The  same  kind  of  diarrhoea  also  happens  in  those  who 
clean  privies,  or  who  are  exposed  to  the  emanations  arising  from 
sewers ;  or  dysentery  or  choleraic  attacks  may  follow  the  exposure. 
Nay,  as  in  instances  recorded  by  Becquerel,  the  instant  disengage- 
ment of  large  quantities  of  putrid  gases,  arising  from  bodies  far 
advanced  in  decomposition,  where  coffins  have  been  opened,  has 
caused  sudden  deaths,  or  has  resulted  in  so  serious  a  state  of  poison- 
ing as  to  give  rise  to  very  grave  illnesses,  having  mostly  a  fatal 

*  See  Dr.  Hunt's  case,  desci-ibed  hy  himself,  in  Pennsylvania  Hospital  Re- 
ports, vol.  i. 


POISONS   AND   TARASITES.  949 

termination.*  In  individuals  who,  in  consequence  of  their  voca- 
tion, are  habitually  brought  in  contact  with  animal  effluvia  and 
are  liable  to  inhale  noxious  gases,  besides  the  attacks  of  diarrhwa 
referred  to,  chronic  disturbances  of  the  stomach  and  liver,  with 
marked  impairment  of  the  general  health,  may  hapjien.  Cases 
of  self-infection  from  ptomaines  resulting  from  decomposition  of 
faecal  matter  lodged  in  the  csecum,  or  by  perforations  taking  place 
from  the  intestine  into  abscesses  near  by,  into  which  the  contents 
of  the  bowel  find  their  way,  occur. 

PAEASITES. 

Parasites  are  organisms  which  become  secondarily  implanted 
within  or  upon  the  body.  Some  parasites  give  rise  to  no  symp- 
toms at  all ;  many  occasion  phenomena  closely  resembling  those 
of  other  irritations.  In  any  case,  the  only  absolutely  convincing 
evidence  of  the  presence  of  a  parasite  is  obtained  by  seeing  it. 

Vegetable  Parasites. — The  chief  vegetable  parasites  have 
been  mentioned  in  connection  with  diseases  of  the  skin ;  the 
oidium  albicans,  present  in  thrush,  and  the  sarcinse  ventriculi, 
have  also  been  described.  All  these  vegetable  growths  can  be 
detected  only  by  the  microscope ;  and,  particularly  in  those  in- 
volving the  skin  or  the  hair,  it  is  of  the  utmost  use  to  employ 
the  liquor  potassse,  under  the  action  of  which  the  structures 
become  transparent. 

The  fungus  that  penetrates  the  internal  tissues,  the  chionyphe 
Carteri,  gives  rise  to  that  terrible  disease  known  as  podelcoma,  or 
the  fungus  foot  of  India, — a  complaint  found  among  the  natives 
of  India  who  go  about  with  naked  feet.  The  fungus,  introduced 
either  through  a  scratch  or  passing  through  the  pores  of  the  skin, 
soon  spreads,  eating  its  way  into  the  bones  of  the  tarsus  and  meta- 
tarsus, and  into  the  lower  end  of  the  tibia  and  fibula,  producing 
a  species  of  caries,  or  rather  a  breaking  up  and  absorption  of  the 
osseous  tissues.  The  fungous  particles  or  masses  are  generally  of 
deep-black  color,  firm  and  globular,  varying  in  size  from  that  of 
a  pea  to  that  of  a  pistol-bullet ;  or  the  fungus  presents  the  ap- 
pearance of  sloughing  tissue,  and  exhibits  chiefly  white  granules ; 
or  it  consists  of  particles  of  pinkish  color.     The  foot  is  enlarged 

*  Traite  d'Hygiene,  3d  edit.,  p.  218. 


950  MEDICAL   DIAGNOSIS. 

about  the  ankle  and  over  the  instep ;  and  on  eaeh  side  of  the 
ankle-joint,  and  on  the  dorsum  as  well  as  on  the  sole  of  the  foot, 
are  small,  soft  swellings,  having  pouting  openings  that  lead  to 
fistulous  canals  communieating  with  the  bones,  which  they  perfo- 
rate in  every  direction.  The  fungous  mass  is  for  the  most  part 
situated  in  the  cavities  in  the  bones,  and  from  the  canals  passing 
to  them  transudes  a  discolored,  glairy,  or  purulent  and  fetid  fluid. 
The  toes  are  distorted,  and  the  muscles  of  the  leg  atrophied  ;  but 
the  fungus  does  not  spread  up  the  leg.  The  tendency  of  the  dis- 
ease is  to  cause  death  by  exhaustion  ;  the  only  remedy  is  amputa- 
tion.*    The  affection  has  also  been  observed  in  this  country. f 

A  similar  disease,  leading  to  local  destruction,  is  the  perforating 
ulcer  of  the  foot.  It  is  very  uncommon  in  this  country,  although  I 
have  known  of  cases ;  in  France  it  is  not  uncommon.  It  is  not 
due  to  a  fungus,  but  occurs  from  defective  vitality  of  the  parts  from 
altered  nerve-supply.  Local  anaesthesia,  lowered  temperature,  and 
a  tendency  to  profuse  perspiration  exist.  The  ulcer  leads  down  to 
diseased  bone.  It  is  generally  situated  on  the  first  or  the  last  toe, 
over  the  articulation  of  the  metatarsal  bone  with  the  phalanx.| 

The  toes  sometimes  drop  off  from  a  disease  which  constricts 
them  and  enlarges  them  beyond  the  point  of  constriction.  The 
affection  is  not  unusual  in  Brazil,  and  seems  to  be  peculiar  to  the 
negro.     It  is  known  as  ainhum.% 

Animal  Parasites. — When  speaking  of  the  affections  of 
particular  structures,  some  of  these  intruders  have  been  men- 
tioned,— those  found  in  the  skin  or  in  the  liver,  for  instance.  It 
remains  to  consider  chiefly  such  of  the  more  important  ones  as 
inhabit  the  hollow  viscera,  certain  solid  organs,  and  the  muscles.  || 

Intestinal  worms  are  the  most  common  of  all  parasites.     The 

*  See  Carter,  in  Transact.  Bombay  Med.  and  Phys.  Soc  ;  and  on  jMycetoma, 

or  the  Fungus  Disease  of  India,  London,  1874;  Aitken,  Practice  of  Medicine; 
Lewis  and  Cunningham,  Arch,  of  Dermatol.,  Oct.  1880. 

I  Kemper,  American  Practitioner,  Sept.  1876. 

X  Savory  and  Butlin,  Med.-Chir.  Transact.,  1879. 

^  Da  Silva  Lima,  Arch,  of  Dermatol  ,  Oct.  1880  ;  Duhring,  Amer.  .Journ. 
Med.  Sci  ,  .Jan   1884. 

II  For  full  description,  see  the  admirable  works  of  Joseph  Leidy,  A  Flora 
and  Fauna  within  Living  Animals,  Smithson.  Pub.,  vol.  v.  ;  Davaine,  Traite 
des  Entozoaires  et  des  Maladies  vermineuses ;  Cobbold,  Entozoa ;  Leuckart, 
Die  Menschlichen  Parasiten,  Leipsic ;  Kucheuuieister,  Manual  of  Parasites. 


POISONS    AND    PARASITES.  951 

general  symptoms  induced  by  them  are  those  of  intestinal  irrita- 
'tion  with  disordered  digestion.  The  appetite  is  capricious ;  the 
bowels  are  irregular,  sometimes  constipated,  sometimes  relaxed ; 
the  abdomen  is  frequently  swollen  and  hard,  and  the  seat  of  dis- 
tressing uneasiness  or  of  colicky  pains  ;  the  tongue  is  furred  ;  the 
breath  is  fetid ;  and  there  is  constant  itching  about  the  nostrils 
and  anus.  The  patient,  furthermore,  grits  his  teeth  during  sleep, 
and  is  often  annoyed  by  nightmare.  Phenomena  indicative  of  a 
greater  or  less  degree  of  nervous  disturbance  are  also  met  with ; 
they  may  range  from  mere  fretfulness  up  to  delirium,  convul- 
sions, chorea,  epilepsy,  or  insanity.  Strabismus  and  amaurosis 
may  be  also  due  to  worms.* 

There  are  many  kinds  of  worms  known  to  infest  the  alimentary 
canal  of  man,  and  they  belong  to  the  order  of  nematoda,  or  round 
worms,  or  to  that  of  cestoidea,  or  tape- worms. 

The  round  worms  are  parasites  of  an  attenuated  or  cylindrical 
form,  and  present  these  varieties  : 

1.  The  ascaris  lumbiicoides,  or  round  worm,  bears  a  consider- 
able resemblance  to  the  common  earth-worm,  from  which  it  is, 
however,  anatomically  different.  It  inhabits  the  small  ini:estine, 
sometimes  finding  its  way  into  the  stomach,  or  even  into  the 
oesophagus,  or  being  discharged  through  the  abdominal  parietes.f 
When  it  ascends  to  the  stomach  and  oesophagus,  it  causes,  before 
it  is  expelled  by  tlie  mouth,  sudden  attacks  of  fever  and  gastric 
derangement,  with  nausea  and  vomiting ;  and  even,  at  times, 
marked  delirium. |  The  worms  have  been  known  to  be  so  numer- 
ous as  to  obstruct  the  intestine. 

2.  The  oxyuris  vermicidaris,  thread-tvorm  or  seat-worm,  is  very 
small,  the  male  being  about  two  lines,  the  female  about  five  lines 
in  length.  The  parasite  is  white,  slender,  and  extremely  active ; 
it  is  found  in  the  anus,  and  causes  intense  itching  of  this  part. 
The  annoyance  is  sometimes  such  as  to  excite  a  suspicion  of  the 
existence  of  piles.  It  may  creep  into  the  vagina,  giving  rise 
there  to  profuse  discharges ;  or  into  the  urethra.  It  affects  chil- 
dren frequently,  but  is  not  uncommon  in  adults. 

3.  The  ascaris  mystax,  a  parasite  which  inhabits  the  cat,  may 


*  Hogg,  Brit.  Med.  Journ.,  July, 

f  Garnier,  L'Union  Medicale,  Oct.  1861. 

X  Schmidt's  Jahrbucher,  No.  10,  1868. 


952  MEDICAL    DIAGNOSIS. 

also  infest  tlie  human  body.  It  is  a  moderate-sized  nematode, 
from  two  to  three  inches  long,  though  the  female  may  reach  about 
four  inches.     Its  head  end  is  spear-shaped. 

4.  The  trichoccjjhalus  diyjar,  or  long  thread- icorin,  is  detected 
in  very  large  numbers  in  the  ileum  near  its  termination,  or  in  the 
colon,  particularly  at  its  head.  It  has  been  found  in  persons 
laboring  under  typhus  or  typhoid  fever,  or  dying  from  cholera  or 
diarrhoea.  It  is  from  an  inch  and  a  half  to  two  inches  in  length, 
and  is  characterized  by  the  hair-like  appearance  of  the  head,  which 
is  generally  buried  in  the  mucous  membrane  of  the  intestine.  It 
is  not  a  common  parasite,  and  it  is  doubtful  whether  its  presence 
gives  rise  to  any  marked  derangement. 

The  iajje-wonns,  or  cestoidea,  are  jointed  entozoa,  of  a  ribbon- 
like form.  They  embrace  the  true  tape-worms,  or  treniadie,  and 
the  bothriocephali.  Of  the  former  there  are  eight  varieties,  all 
of  which  have  been  found  in  man,  though  only  two — the  solium 
and  the  mediocanellata — are  at  all  common.  Yet  recent  researches 
show  that  the  taenia  saginata  is  rapidly  spreading  over  Western 
Europe.*  The  bothriocephalus  latus  is  the  usual  species  of  both- 
riocephalus  met  with  in  the  human  intestine;  it,  too,  is  increasing 
greatly  in  Europe,  and,  it  is  said,  in  Texas,  particularly  in  the 
western  portions.f 

The  taenia  solium,  or  j^ork  tape-worm,  consists  of  an  immense 
number  of  joints  in  connection  with  a  single  head.  It  may  attain 
an  enormous  length,  and  inhabits  chiefly  the  small  intestines. 
The  researches  of  Kuchenmeister,|  Yon  SIebold,§  and  others 
have  shown  that  its  eggs  become  developed  into  the  cydicercus 
cellulosse  discerned  in  the  muscles  of  the  pig,  rabbit,  and  other 
animals  whose  flesh  is  used  as  food.  Cysticerci  have  also  l)een 
detected  in  the  muscles,  the  cellular  tissue,  the  brain,  the  spinal 
cord,  the  heart,  and  the  liver  of  man,  and  are  most  commonly 
met  with  in  middle  age  and  in  the  destitute ;  they  are  the  most 
frequent  parasite  in  the  eye.||     They  cannot,  as  a  rule,  be  diag- 

*  Von  Zehender,  Parasitical  Diseases  of  the  Eye,  Bowman  Lectures, 
Deutsch.  Med.  Wochenschr.,  No.  50,  1887. 

t  Colman,  quoted  in  Sajous's  Annual,  vol.  i.,  1890. 

X  See  Manual  of  Animal  and  Vegetable  Parasites,  Syd.  Soc.  transl.,  1857. 

§  Origin  of  Intestinal  "Worms,  t6.,  1857. 

II  Berengcr-Feraud,  Le9ons  de  Clinique  sur  les  Taenias  de  i'Homme,  Paris, 
1888. 


POISONS   AND    PARASITES. 


953 


nosticated,  except  they  be  in  positions  in  which  they  can  be  seen 
or  felt,  or  the  little  tumors  they  occasion  in  the  subcutaneous 
tissues  are  extirpated  and  examined.  In  the  brain  their  chief 
symptom  is  violent  and  rapidly-increasing  epilepsy.  Being  once 
introduced  into  the  alimentary  canal,  they  find  there  a  nidus  in 
which  to  undergo  development  into  the  tape-worm. 

The  tape-worm  is  nourished  from  its  head,  the  newly-created 
segments  pushing  those  already  formed  before  them,  so  that  the 

caudal  extremity  is  the  oldest 
portion  of  the  animal.  Each 
segment  is  flat  and  rectangular, 
and  contains  both  a  male  and 
a  female  organ,  the  orifices  of 
which  are  joined  at  the  apex 
of  a  lateral  papilla.  In  the 
icenia  solium,  the  papillae  are 

Fig.  73. 


Fig    72. 


Segments  of  taenia  solium.     Drawn  fruni  a 
specimen. 


Heads  of  ttenise,  raagnified,  except  the 
small  central  figure,  which  represents  the 
head  and  neck  of  tasnia  solium,  natural  size. 
The  figure  to  the  left  is  the  taenia  solium, 
that  to  the  right  the  mediocanellata. 


arranged  alternately  at  one  side  and  the  other.  The  size  of  the 
segments  increases  gradually  toward  the  caudal  extremity,  the 
largest  being  three  or  four  lines  in  breadth.     There  may  be  up- 


954  MEDICAL   DIAGNOSIS. 

wards  of  eight  lumJred  segments,  and  the  worm  may  measure 
above  ten  feet ;  it  has  been  stated  even  to  be  above  thirty.  Upon 
the  head,  which  is  about  as  large  as  that  of  a  i)in,  is  a  double 
circle  of  hooks  contained  in  sacs,  and  around  this  circle  are  ar- 
ranged four  sucking-cups  or  mouths.  The  slender  neck  exhibits 
no  segmentation.  The  suckin<>:-disks  in  the  toenla  mcdiocanellala 
are  larger  than  those  in  the  taenia  solium,  but  the  head,  whi(;h 
is  of  blackish  appearance,  and  obtuse,  has  no  hooks. 

The  form  of  tape-worm  most  frequently  seen  in  this  country  is 
the  taenia  mediocanellata,  which  is  usually  found  in  beef.  Lcidy 
states,  as  the  result  of  a  large  experience,  that  he  has  rarely 
encountered  the  pork  tape-worm,  tsenia  solium,  as  a  parasite  in 
the  human  intestines.  The  habit  of  eating  partially-cooked  beef 
is  the  cause  of  much  of  the  infection  with  tape-worm. 

Tsenia  occasions  disordered  digestion,  colic,  cramps,  a  feeling  of 
uneasiness  in  the  abdomen,  irritation  of  the  mouth,  nose,  and  anus, 
ausemia,  headache,  dizziness,  disturbed  sleep,  mental  depression, 
emaciation,  cough,  fainting-fits,  cutaneous  eruptions,  and  various 
cerebro-spinal  affections,  such  as  convulsions  and  epilepsy  ;  yet 
there  are  no  absolute  data  for  the  diagnosis  of  tliis  parasite,  except 
its  appearance  in  the  discharges.  In  order  that  relief  be  perma- 
nent, the  head  must  be  expelled. 

The  bothriocephalus  lotus,  tsenia  lata,  or  broad  tape-ivorm,  differs 
from  the  common  tape-worm  in  having  no  lateral  papillae  alter- 
nately arranged,  but  a  single  one  at  the  centre  of  each  segment; 
the  segments  themselves  are  much  broader,  and  with  the  breadth 
greatly  preponderating  over  the  length ;  the  head  is  of  elongated 
form,  has  no  hooks  upon  it,  and  only  a  pair  of  fissures  instead  of 
the  four  mouths  of  the  taenia  solium,  and  we  find  no  traces  of 
joints  until  about  three  inches  from  the  head.  The  parasite  is 
of  yellow  or  grayish-white  color. 

Echiaococci  belong  also  to  the  family  of  the  tseniadae.  They 
may  take  up  their  abode  in  the  substance  of  almost  any  organ  in 
the  body,  and  are  the  immature  brood  of  a  species  of  taenia.  They 
consist  of  a  vesicle  having  at  one  .portion  of  its  wall  a  head,  upon 
which  are  six  booklets  circularly  arranged.  The  whole  animal  is 
surrounded  by  an  investing  membrane,  which  may  burst  and  allow 
it  to  escape  ;  the  term  hydatid  designates  the  enveloping  cyst.  It 
forms  when  the  taenia  embryo  has  bored  its  way  to  its  resting- 


POISOiS'S   AND    PARASITES.  955 

jjlace  in  the  liver,  or  has  been  carried  with  the  circulation  to  other 
organs.  The  echinococcus,  unlike  other  larval  tieniie,  retains  a 
more  or  less  globular  figure,  in  place  of  exhibiting  a  head,  neck, 
and  body.  When  the  echinocoeci  are  arrested  in  their  normal 
development  and  are  barren,  not  attaining  to  the  production  of 
scolices,  they  give  rise  to  cysts  with  walls  consisting  of  distinctly- 
developed,  concentric  layers,  and  having  a  peculiar  gelatinous 
trembling, — the  so-called  acephalocysts ;  and  the  same  may  be  said 
of  abortive  cysticerci,  embryonic  forms  of  tsenia,  which,  some  sup- 
pose, may  also  occasion  the  hydatid  cysts ;  though  others  maintain 
that  the  hydatids  proceed  from  only  one  form  of  t£enia, — the  taenia 
echinococcus. 

The  familv  of  the  dlstomata,  belong-ino;  to  the  order  of  fluke- 
like  parasites,  is  not  at  all  uncommon  in  man. 

A  species  of  distoma,  measuring  from  eight  to  fourteen  lines  in 
length,  called  the  distoma  hepaticum,  usual  in  the  liver  and  gall- 
bladder of  the  sheep,  has  been  seen  in  the  human  liver  and  gall- 
duct,  and  also,  it  is  said,  in  abscesses  of  the  scalp.  Other  species 
of  distoma  have  been  found  in  the  portal  vein,  ureters,  kidneys, 
and  bladder,  and  upon  the  intestinal  mucous  membrane ;  yet  in 
the  portal  vein  and  its  larger  branches — a  common  seat  of  the 
distoma — ^the  parasite  produces  little  or  no  appreciable  derange- 
ment ;  but  when  in  the  intestine  it  may  give  rise  to  congestion 
of  the  membrane,  extravasation  of  blood,  and  the  symptoms 
of  dysentery.  This  has  been  specially  noticed  of  the  distoma 
haematobium,  or  Bilharzia  hsematobia,  a  worm  which  is  common 
in  Egypt,  and  which  has  been  found  to  be  the  cause  of  the  hsema- 
turia  prevalent  at  the  Cape  of  Good  Hope  and  at  the  Mauritius. 
The  entrance  into  the  body  is  mainly  through  the  urethra  in 
persons  bathing. 

Filarise  have  been  met  with  in  the  urine.  Lewis  *  regards  the 
hsematozoon  he  has  described  as  a  filaria.  The  filaria  sanguinis 
hominis  is  supposed  to  get  into  the  system  chiefly  through  the 
bites  of  mosquitoes,  or  by  entering  the  skin  of  bathers.  It  gives 
rise  to  considerable  pain  in  the  loins,  and  leads  to  both  bloody 
and  chylous  urine,  and,  according  to  Manson,  to  the  elephantiasis 


*  Lancet,  vol.  ii.,  1873  ;  see  also  Manson,  Medical  Times  and  Gazette,  1881 ; 
Mackenzie,  On  the  Periodicity  of  Filarial  Migration,  Lancet,  1881. 


950  MEDICAL    DIAGNOSIS. 

of  the  tropics.  Ma.stin*  proves  that  the  filaria  in  the  United 
States  may  be  the  cause  of  ehylocele  of  tlie  tunica  vaginalis  testis. 
A  worm  calk'tl  the  tifrongylns  gig^ifi  has  been  observed  in  the 
kidneys.  It  produces  htematuria,  continuous  pain,  and  an  abdom- 
inal tumor,!  and  may  lead  to  dropsy  and  death. ;{: 

The  dochmius  duodenalls  is  a  worm  producing;  a  peculiar  amemia 
bv  sucking  blood  from  the  walls  of  the  duodenum.  It  has  been 
found  especially  among  brickmakers,  miners,  and  men  working 
in  tunnels,  and  the  disorder  has  been  identified  by  Leichenstern  § 
with  the  so-called  Egyptian  chlorosis,  tropical  chlorosis,  and 
brickmaker's  annemia.  It  has  spread  largely  through  Italian 
and  Polish  laborers  employed  in  building  tunnels,  in  mining, 
and  in  brickmaking.  Anchylodomiasis,  as  the  disease  caused  by 
the  parasite  is  called,  is  characterized  by  marked  anaemia,  by  diges- 
tive disorder,  abdominal  pains,  and  bleeding  from  the  bowels. 
There  is  a  greater  tendency  to  retinal  hemorrhage  than  in  simple 
anaemia.  II 

Fly  jxircmtes  may  be  found  in  the  dejections  from  the  bowel 
and  in  the  urine,  producing  local  irritation  of  the  intestine  or  the 
bladder. 

The  parasites  which  chiefly  occupy  the  areolar  tissues  or  the 
muscles  remain  to  be  described.  Of  these  there  are  t\\o  of  special 
importance. 

One  is  the  jilaria  medinensis,  dracunculus,  or  Guinea-ivorm. 
This  is  a  very  slender,  flat,  finely-ringed  worm,  which  intro- 
duces itself  into  the  subcutaneous  cellular  tissue  :  here  it  grows 
rapidly,  and  gives  rise  to  swelling,  with  more  or  less  inflamma- 
tion ;  and  sometimes  to  severe  constitutional  disturbance.  After 
a  time  the  swelling  points,  and  breaks,  and  the  worm  may  be  laid 
hold  of  and  carefully  twisted  around  a  little  piece  of  stick  or  a 
quill  until  it  is  extracted  entire ;  if  broken  off,  the  eggs  with 
which  it  is  filled,  getting  into  the  wound,  will  become  the  agents 
of  fresh  mischief.     Many  of  these  worms  may  be  found  in  the 

*  Medical  Kecord,  Sept.  1888. 

t  Magner,  Journ.  de  Med.  de  Bordeaux,  Feb.  1888. 
X  George,  Med.  and  Surg.  Reporter,  Aug.  1888. 

§  Schmidt's  Jahrbiicher,  Sept.  1888;  also,  Internationale  Klinische  Rund- 
schau, Oct.  1888. 

II  Discussion  at  the  Brit.  Gynaecol.  Soc,  Brit   Med.  Journ.,  June,  1888. 


POISONS    AND    PARASITES.  957 

same  patient,  occasioning  great  annoyance  and  distress,  even  fatal 
exhaustion ;  but  it  is  stated  that  there  is  often  only  one  present. 
The  number  may  vary  between  this  and  fifty.  Some  worms  are 
twelve,  others  forty  inches  long,  or  even  more.  According  to 
Busk,  the  parasite  grows  in  the  human  areolar  tissue  at  the  rate 
of  about  an  inch  a  week.  Though  it  is  most  frequently  found 
in  the  lower  extremities,  it  has  been  observed  to  appear  in  the 
socket  of  the  eye,  in  the  mouth,  the  cheeks,  the  ears,  and  under 
the  tongue  and  the  scalp.  It  migrates  rapidly  from  one  part  of 
the  body  to  another.  Where  it  exists,  a  pricking  or  an  itching 
heat  is  felt ;  a  vesicle  forms  when  the  worm  is  about  coming  to 
the  surface,  and  this  vesicle  opens,  leaving  an  angry-looking  ulcer, 
in  the  centre  of  which  the  parasite  shows  itself  Phlegmonous 
spots  may  appear  all  over  the  body  in  which  specimens  of  dra- 
cunculus  are  found.*  The  period  of  incubation  is  from  eight  to 
twelve  months :  a  year  often  elapses  before  the  Guinea-worm 
makes  itself  manifest  in  the  human  body.f  The  disorder,  com- 
mon in  Asia  and  in  Africa,  is,  fortunately,  one  with  which  we  are 
unacquainted. 

Trichina  spiralis. — This  parasite  was  discovered  by  Owen  in 
1835  in  human  muscles  taken  from  the  dissecting-room;  it  was 
subsequently  found  by  Leidy  in  the  animal  which  it  most  infests, 
the  pig ;  but  it  was  not  looked  upon  as  other  than  harmless  until 
in  1860  Zenker  proved  that  triehinse  may  exist  free  in  the  muscles 
of  man,  that  they  are  encapsuled  only  after  some  time,  and  that 
they  are  the  cause  of  a  very  serious  disease, — so  serious  that 
whole  families  have  perished  from  its  effects  amid  great  suffer- 
ing, and  that,  for  instance,  in  the  small  village  of  Hadersleben,  of 
two  thousand  inhabitants,  three  hundred  were  affected,  of  whom 
eighty  died.| 

The  parasite  is  always  introduced  into  the  body  by  eating  ham, 
pork,  or  sausages  made  from  the  flesh  of  pigs  containing  trichinae. 
It  is  very  probable  that  the  hogs  themselves  obtain  themi  from 
rats,  in  which  they  are  common.  It  has  also  been  stated  that 
trichinae  may  exist  in  beef;  but  this  is  not  generally  admitted. 

*  Woskresensky,  quoted  in  Sajous's  Annual,  vol.  i.,  1889. 

f  Aitken's  Practice  of  Medicine,  vol.  i. 

%  Virchow,  Die  Lehre  von  den  Trichinen,  p.  33. 


958 


MEDICAL    DIAGNOSIS. 


The  trichina  spiralis  is  the  jiivcnik'  condition  of  a  small  nema- 
tode worm.  It  is  incapable  of  reproduction,  and  becomes  fruitful 
only,  whether  encapsuled  or  not,  when  introduced  into  the  intes- 
tine. After  being  swallowed,  if  it  be  encysted,  the  capsule  is 
dissolved,  and  tlie  parasite  remains  in  the  intestine,  where  it  rapidly 
grows  to  three  or  four  times  its  former  size,  and  within  two  days 

Fig.  74. 


Trichina  in  receut  human  muscle,  Ulven  tlie  thirteenth  day  uf  illness.     (.Vfter  Dallon.) 


attains  its  full  sexual  maturity.*  By  the  sixth  day  the  female 
trichina  contains  an  abundance  of  living  young,  and  begins  to 
throw  off  minute  embryos,  which  are  born  without  any  covering 
from  the  egg,  and  at  once  begin  to  migrate  to  the  muscular  struc- 
tures.   They  pass  to  them  through  the  intestinal  walls,  the  mesen- 


*  Leuckart,  XJnter?uchungen  iiber  Trichina  Spiralis,  Leipsic,  1866. 


POISONS  AND  parasitf:s.  959 

tery,  and  the  blood-vessels.*  When  they  rcaeh  the  muscles  they 
grow  there,  but  do  not  generate  others.  A  single  female  triehina 
may  remain  in  the  intestine  for  three  or  four  weeks,  or  even  longer, 
and  may  give  birth,  it  is  estimated,  to  from  two  hundred  to  two 
thousand  embryos,  which  find  their  way  to  the  muscles;  while  the 
trichinse  that  have  been  swallowed  never  pass  beyond  the  intestine. 
In  six  or  eight  weeks  at  furthest  the  intestinal  trichinse  have,  as  a 
rule,  died  and  left  the  intestinal  canal ;  four  or  five  weeks  may  be 
stated  to  be  their  average  life.f 

When  the  young  trichina  arrives  in  the  muscles,  it  begins  at 
once  to  destroy  the  muscular  texture.  It  penetrates  and  irritates 
the  sarcolemma,  leading  to  its  gradual  thickening  and  to  an 
exudation  which  fixes  the  worm  to  a  particular  spot.  Thus  is 
formed  the  cyst  which  eneapsules  the  parasite,  and  which  plays 
so  important  a  part  in  its  subsequent  destruction.  The  cyst  in 
the  human  subject  is  oval  or  spindle-shaped,  and  in  its  centre 
the  worm  lies  coiled  up.  It  takes  a  month  or  months  for  the 
cyst  to  form  completely,  though  at  the  end  of  the  third  week 
after  migration  the  inflammatory  irritation  has  reached  its  highest 
point,  and  the  trichina  is  by  that  time  full-grown.  Several 
trichinse  may  wander  in  the  same  track,  and  ultimately  be  en- 
closed in  the  same  mass  of  exuded 
matter.     Two  are  not  unfrequently  ■^^'^-  ^^ 

seen   intimately  coiled  up,  and    the 
number  may  rise  to  five.| 

After  the  perfect  formation  of  the 
cyst,  further  changes  take  place  in  it. 
The  masses  of  nuclei  in  the  spaces 

at     both    extremities    of    the    capsule      Trichina  capsule  ^vith  shell-like  caUa- 

^  leous  deposits.     (After  Leuckart.) 

become    of  greenish    hue ;    dark   or 

black  particles  of  carbonate  of  lime  and  magnesium  are  deposited. 
The  calcareous  mass  extends,  and  gradually  covers  the  whole 
parasite,  while  around  the  prolongations  of  the  cyst  fat-cells  are 
deposited.     The  whole  process  is  very  destructive  to  the  flesh- 


■mUTlTTTTmT.^ 


*  Dal  ton,  Transactions  of  the  New  York  Academj'  of  Medicine,  1864; 
Fiedler,  Archiv  f.  Heilk.,  v.,  1864,  and  Heller,  in  Ziemssen's  Cyclopsedia 

■f  Leuckart,  op,  cit. 

X  Thudichum,  Blue  Book.  Seventh  Eeport  of  the  Medical  Officer  of  the 
Privy  Council,  p.  367. 


960  MEDICAL   DIAGNOSIS. 

worm,  and  it  is  tluis  that  the  disorder  is  cured.  But  it  is  apt  to 
be  niontlis  before  this  result  is  accomplished.  Nay,  as  we  know 
from  two  cases  recorded  by  Virohow,  neither  the  encapsuling  nor 
the  calcareous  transformation  kills  the  worms  of  necessity  at  all 
speedily  ;  for  in  the  one  case  they  had  remained  alive  for  eight, 
in  the  other  for  thirteen  and  a  half  years  after  the  infection,*  and 
in  one  instance  mentioned  by  Turner f  they  were  alive  and  active 
after  twenty-six  years. 

The  appearances  described  are  not  to  be  recognized   by  the 
naked  eye.     For  the  study  of  the  cyst  a  low  magnifying  power 

only  is  requisite.      To  investigate 
^^°-  "^-  the  structure  of  the  worm  requires, 

TT-j  however,  one  of  at  least  300  diarae- 
I  ters.  The  parasite,  being  only  ^  to 
tj       h  of  a  line  in  length  and  about  -^ 

'       of  a  line  in  thickness,  will  be  seen 
I  .  . 

with  this  power  to  have  an  ante- 
rior extremity  that  is  narrow  and 
pointed,  and  often  to  show  an  ali- 
mentary   canal     beginning    by    a 
^       mouth,  and  followed  by  an  oesopli- 
rl      agus  surrounded  by  cells. 
■  j  The  number  of  trichinre  in  the 

^  sd  issi  4  A^^igV        muscles  may  be  from  several  hun- 
_        ,  ,  ,  ,,  ,.     .         ,      dreds  to  as  many  millions.     Now, 

Encapsuledchalky  concretions  in  muscle,  •'  ' 

^Zxyt^tt  *(iftlrLeuckart"f '"^  ''''""'    "^  accordaucc  witli  their  number  in 

the  muscles,  with  the  character  of 
the  changes  which  there  take  place,  and  with  the  quantity  in  the 
intestines,  will  vary  the  extent  of  constitutional  derangement  and 
the  signs  of  local  irritation.  Thus  the  symptoms  and  the  dangers 
of  trichiniasis  are  not  always  the  same  :  we  find,  indeed,  all  the 
degrees  of  the  malady.  When  merely  a  few  thousand  trichinae 
occupy  the  muscles,  there  are  chiefly  muscular  pains  with  stiffness 
and  general  debility  ;  signs  which  gradually  cease  as  the  worms 
become  fully  encapsuled  and  cretaceous  alterations  occur.  When 
the  muscles  are  occupied  by  many  millions  of  the  flesh-worms, 

*  Virchow,  op.  cii.,  p.  40. 

t  Lancet,  London,  May,  1889. 


POISONS   AND   PARASITES.  9f)l 

the  local  phenomena  are  much  more  severe ;  there  may  be  almost- 
complete  immobility  of  the  whole  body,  the  muscles  of  respira- 
tion and  of  deglutition  are  implicated,  irritative  fever  and  the 
general  cachexia  are  marked,  and  tlie  patient  is  apt  to  perish  by 
gradual  exhaustion,  or  in  consequence  of  the  disordered  respira- 
tory function,  or  of  some  pulmonary  complication.  The  presence 
of  large  numbers  of  trichinae  in  the  intestine  produces  diarrhcea, 
vomiting,  abdominal  pain  and  tenderness ;  or  the  worms  may 
shortly  after  being  swallowed  give  rise  to  a  kind  of  cholera  mor- 
bus. Should  the  signs  of  the  affection  not  appear  until  from 
twenty-one  to  twenty-five  days  after  the  use  of  the  infected  meat, 
and  take  the  form  similar  to  acute  rheumatism  of  the  joints, 
there  ai'e  not  as  many  trichinae  present  as  in  the  choleroid  or  the 
typhoid  variety  of  the  malady,  each  of  which  Ruj^precht*  has 
told  us  shows  from  five  to  ten  millions. 

Speaking  generally,  we  may  recognize  in  trichiniasis  three 
stages :  the  first,  lasting  about  a  week,  during  which  the  trichinae 
are  being  generated  in  the  intestines  and  in  which  we  find  only 
signs  of  gastro-intestinal  irritation ;  the  second,  the  passage  of 
the  brood  into  the  muscular  textures,  and  the  disturbances  it 
there  occasions ;  the  third,  the  retrogressive  formation,  which 
fairly  sets  in  about  three  or  four  weeks  after  the  beginning  of 
the  second.  Now,  it  is  this  stage  which  yields  the  most  striking 
manifestations  of  the  malady: — loss  of  appetite;  pasty  taste  in 
the  mouth;  nausea  or  vomiting;  dry,  somewhat  coated  tongue; 
diarrhoea;  abdominal  pain  and  meteorism ;  prostration;  fever, 
with  a  quick  pulse  and  copious  sweating;  oedematous  swelling 
of  the  face,  followed  in  grave  cases  by  almost  general  anasarca ; 
sensitiveness  of  the  skin  and  the  muscles  to  the  touch,  or  pain- 
fulness  when  the  latter  are  moved,  and  their  contraction  and 
difficult  motion;  dyspnoea;  apathy;  sleepless  nights;  nocturnal 
attacks  of  abdominal  neuralgia ;  and  emaciation. 

Let  us  examine  some  of  these  phenomena  more  in  detail : 

The  fever  is  a  marked  symptom.     It  sets  in  early,  owing  to 

the  intestinal   irritation,  though  it  is  not  until   the  end   of,  or 

after,  the  first  week,  after  therefore  the  migration  of  the  young 

trichinae  has  fairly  begun,  that  it  is  strikingly  developed.     It 

*  Vierteljahrsschrift  fiir  Ges.  Med.,  Oct.  1880. 
61 


9(32 


MEDICAL    DIAGNOSIS. 


is  then,  except  in  those  cases  in  Mhieh  fresh  importations  of 
trichinae  from  the  intestine  in  considerable  numl)ers  produce  ex- 
acerbations, a  continuous  fever,  with  a  pulse  ranging  from  100  to 
130,  with  scanty  urine  and  profuse  perspirations  having  a  very 
unpleasant  odor  and  which  may  continue  in  certain  parts  of  the 
body  after  the  general  sweating  has  entirely  ceased.  The  tem- 
perature is  about  101°  Fahr.,  though  it  may  pass  to  104°  and 
105°  ;  yet  it  does  not,  as  a  rule,  reach  the  high  heat  which  is 
observable  in  other  continuous  fevers.     But  it  is  especially  in  the 

Fig.  77. 


Trichina  spiralis.     Magnified  300  times.      {.\fter  Virchow.) 


profuse  perspirations,  the  absence  of  enlargement  of  the  spleen 
and  of  an  eruption,  the  swelling  of  the  face,  the  muscular  symp- 
toms, and  in  a  very  red  color  of  the  visible  mucous  membranes, 
that  the  points  of  difference  lie  between  the  febrile  excitement  of 
trichiniasis  and  typlioid  fever, — a  malady  Avhich,  on  account  of 
the  continuous  fever,  the  prostration,  the  diarrhoea,  and  the  su- 
damina,  it  resembles.  In  light  cases  of  trichiniasis  there  may  be 
no  fever,  or  there  may  be  a  fever  more  of  intermittent  or  remit- 
tent character.     The  appearance  of  the  face  may  be  like  that  of 


POISONS    AND    PARASITES.  963 

typhus  fever,  in  which  disease,  liowever,  the  muscular  pains  are 
wanting.  * 

The  oedema  marks  the  beginning  of  the  second  stage  of  the 
affection.  It  manifests  itself  first  in  the  eyelids,  about  the  seventh 
day  of  the  disease,  and  is  attended  with  a  catarrhal  state  of  the 
conjunctiva,  with  dilated  pupils,  great  susceptibility  to  light, 
diminished  power  of  accommodation,  and  pain  in  moving  the 
eye.  The  swelling  may  extend  over  the  whole  face,  and  is  some- 
times associated  with  flushing.  It  is  uninfluenced  either  by  the 
sweats  or  by  the  diarrhoea,  but  lessens  generally  very  much,  or 
even  disappears,  after  lasting  eight  or  nine  days,  though  it  may 
vanish  in  a  few  days ;  at  the  same  time,  too,  the  diarrhoea  is  apt 
to  diminish,  or  even  gradually  to  cease.  But  instead  of  the 
oedema  subsiding,  it  may  extend  to  the  chin,  to  the  arms  and  legs, 
and  to  the  back  -;  or  it  may  show  itself  in  the  extremities  subse- 
quently to  the  disappearance  from  the  face,  and  shortly  afterward 
become  perceptible  over  the  trunk.  In  some  cases  an  anasarcous 
condition,  beginning  at  the  ankles  and  extending  upward,  occurs 
during  convalescence,  and  is  of  long  duration.  It  is  then  prob- 
ably connected  with  the  state  of  the  blood;  whereas  the  oedema 
happening  earlier  in  the  malady  is  thought  to  be  due  to  the  press- 
ure upon  the  arteries,  exerted  by  the  parasites  and  the  exudation 
of  plastic  material  they  produce,  or,  in  accordance  with  the  ob- 
servations of  Thudichum,  to  their  presence  within  the  lymphatic 
spaces,  vessels  and  glands,  and  blood-currents,  f  The  dropsical 
swelling  of  trichiniasis  is  not  associated  with  albumen  in  the 
urine,  for,  except  an  increased  quantity  of  uric  acid,  the  urinary 
secretion  contains  no  abnormal  ingredient.  The  quantity  of  urine 
is  much  diminished.  The  trichinse  may  at  times  be  detected  in 
the  passages  from  the  bowels.  Boils,  acne,  and  ecthyma  are  often 
noticed  after  the  oedema  has  passed  away.| 

The  muscular  symptoms  begin  in  the  second  stage,  at  about  the 
tenth  day,  with  pain  and  stiffness  in  the  limbs.  Soon  at  all  parts 
of  the  body  the  muscles  give  the  impression  of  being  swollen  ;  they 
are  extremely  painful  when  touched  or  moved ;  and  the  patient 

*  See  Clinical  Lecture  on  Acute  Trichiniasis,  reported  in  Medical  News  and 
Abstract,  March   1881. 

f  Thudichum,  loc.  cii.,  pp.  362  and  386.       ^ 
J  Meissner,  Schmidt's  Jahrbiicher,  No.  4.  1868. 


904  MEDICAL    DIAGNOSIS. 

lies  in  consequence  as  quietly  as  possible,  or,  in  very  severe  in- 
stances of  the  affection,  like  a  paralyzed  person.  The  immobility 
is  also  partially  clue  to  the  retracted  state  of  the  muscles  which 
occurs  in  bad  cases,  and  which  produces  a  condition  similar  to 
a  true  spasm,  manifest  for  instance  in  the  semi-flexed  position  of 
the  extremities,  and  in  the  rigid,  trismus-like  setting  of  the  jaws. 
The  disturbance  of  function  of  certain  muscles  becomes  particu- 
larly evident.  The  disorder  of  the  muscles  of  the  eye  has  already 
been  spoken  of;  we  encounter,  besides,  impaired  hearing,  diffi- 
culty of  deglutition,  and  loss  of  voice,  from  the  muscles  of  the 
ear,  of  the  pharynx,  and  of  the  larynx  being  filled  with  trichiniv. 
The  respiratory  muscles  are  commonly  much  affected,  and  we  find 
hurried 'and  shallow  breathing,  and  at  times  considerable  distress 
in  respiration.  The  muscles  of  the  heart  usually,  and  the  un- 
striped  muscles  of  organic  life  constantly,  escape  infection  ;  and, 
as  the  trichinae  wander  to  the  front  of  the  body,  rather  than  to  the 
back,  the  muscles  anteriorly  are  more  infested  than  those  poste- 
riorly. A  flabby  condition  of  the  muscles,  with  a  certain  want 
of  power  and  painful  sensation  on  motion,  has  been  noticed  as  an 
early  symptom  and  preceding  their  marked  implication.* 

The  marked  muscular  pain,  the  stiffness,  the  fever,  the  profuse 
sweats,  the  acid  urine,  simulate  the  signs  of  acute  rhciimafism  ; 
but  we  find  in  triehiniasis  diarrhoea,  no  articular  swelling,  and- no 
heart-complications.  Error  is  more  apt  to  happen  M'ith  reference 
to  acute  muscular  rheumatism.  But  the  signs  of  prostration  and 
of  gastro-intestinal  irritation  are  here  wholly  wanting. 

The  condition  of  the  respiratory  muscles  gives  rise,  as  already 
stated,  to  the  embarrassed  respiration,  but  it  is  not  the  only  cause 
of  the  pulmonary  symptoms.  Yet,  whether  it  alone  leads  to  con- 
gestion of  the  lung  and  to  bronchitis  or  pleuritis,  or  other  causes 
concur  in  producing  them,  it  is  certain  that  these  states  are  usual. 
They  are  not  uncommonly  combined  with  pneumonia,  which  ap- 
pears suddenly,  and  selects  the  lower  portion  of  the  left  lung  by 
preference,  occurs  about  the  twenty-sixth  day  of  the  disease,  and 
is  apt  to  prove  fatal.  The  sputa  consist  of  dark  unmixed  blood  ; 
and  the  pneumonia  is  thought  to  be  due  to  a  trichinous  embo- 
lism, the  clots  being  derived  from  thrombi,  which,  forming  in 

*  Krntz,  Die  Trichinen-Krankheit  im  Hadersleben,  Leipsic,  1867. 


POISONS    AND    PARASITES.  965 

the  venous  system,  are  sent  through  the  l:ieart  into  the  lungs.* 
Limited  catarrhal  pneumonia  may  be  also  met  with. 

If  the  patient  escape  a  serious  pulmonary  complication,  if  he 
have  strength  enoug-h  to  withstand  the  weeks  of  irritative  fever 
and  exhaustion,  he  enters  at  the  end  of  a  month  or  of  five  or  six 
weeks  of  suffering  upon  a  gradual  convalescence.  The  fever  de- 
clines ;  the  respiration  is  less  accelerated ;  the  perspirations  are  far 
less  copious;  the  urine  increases  in  quantity;  the  pains  decrease ; 
and  by  about  the  sixth  week  of  the  malady  the  patient  is  suffi- 
ciently free  from  pain  to  lie  on  his  side,  and  is  thus  able  to  sleep. 
The  pallor  of  his  countenance  gives  way  to  a  healthier  hue ;  his 
appetite  becomes  insatiable ;  and  he  moves  his  limbs  with  more 
and  more  freedom.  But  it  is  a  long  time  before  he  regains  his 
full  muscular  power.  Indeed,  this  may  be  always  somewhat 
impaired ;  though  we  have  the  authority  of  Rupprecht  for  the 
statement  that  it  may  entirely  return,  and  perfect  health  be  recov- 
ered. In  some  cases  convalescence  does  not  set  in  for  four  months; 
in  others  it  is  greatly  retarded  by  boils,  by  inflammation  of  the 
lymphatic  glands,  and  by  dropsy.  The  change  in  the  power  of 
accommodation  of  the  eye  may  also  alter  but  slowly.  Children 
convalesce  more  quickly  than  adults.  They  suffer,  in  truth,  less 
from  the  disease,  and  are  not  very  subject  to  it. 

The  diagnosis  of  the  malady  has  been  made  evident  while 
discussing  the  symptoms.  At  first  the  signs  of  gastro-intestinal 
catarrh,  the  vomiting,  the  slight  fever,  the  perspiration,  the 
muscular  feebleness,  are  the  most  significant,  and  these  early 
manifestations  might  be  mistaken  for  irritant  poisoning ;  we  can 
tell  their  meaning  prior  to  the  marked  development  of  the  phe- 
nomena in  the  muscles  only  by  the  detection  of  trichinae  in  the 
stools.  The  same  may  be  said  of  cholera  morbus.  Again,  it 
must  be  borne  in  mind  that  in  some  cases  of  trichiniasis  the  first 
symptoms  of  the  complaint  do  not  happen  for  two  or  three  weeks 
after  the  infected  meat  has  been  eaten  ;  and  that  in  others  it  runs 
a  chronic  course  and  the  whole  disease  is  very  protracted.  The- 
so-called  ^'  sausage  poisoning"  not  dependent  on  trichinae,  differs 
from  trichiniasis  in  its  rapid  course  and  in  the  quick  appearance 
of  the  symptoms  after  the  spoiled  sausages  have  been  partaken  of. 

*  Rupprecht,  Trichinen-Krankheit,  18G4. 


966  MEDICAL   DIAGNOSIS. 

In  pcricu'tcritis  nodosa  the  severe  imiscular  pains  are  associated 
with  thickening  of  the  vessels,  and  an  examination  of  the  muscles 
will  explain  the  cause  of  the  muscular  affection.  Indeed,  in  any 
instance,  no  matter  what  be  the  complaint  trichiniasis  may  simu- 
late, there  is  but  one  means  of  determining  the  presence  of  the 
flesh-Avorms  positively, — to  examine  a  piece  of  muscle.  This  may 
be  ett'ected  by  cutting  down  upon  a  nniscle  and  removing  sufficient 
of  its  structure  for  a  microscopical  examination,  or  by  using 
Middeldorpif' s  harpoon  or  Duehenne's  or  Hart's  trocar. 

Owing  to  the  oedema,  and  particularly  the  axlema  of  the  eye- 
lids and  face,  the  malady  may  be  confounded  with  BrigMs  disease. 
But  the  utter  absence  of  albumen  in  the  urine  distinguishes  it. 
The  physical  signs  separate  the  dyspnoea  it  occasions  from  that  of 
cardiac  disease;  and  the  sweats  and  the  muscular  symptoms  of 
trichiniasis  tell  us  what  we  are  dealing  with. 

The  chief  epidemics  of  trichiniasis  have  occurred  in  Germany ; 
but  we  have  not  escaped  in  this  country.*  Nor  can  we  claim 
that  our  hogs  are  not  infested.  On  the  contrary,  the  report  of  the 
Chicago  Academy  shows  that  about  one  in  fifty  contains  trichinae 
in  the  muscles.f    Our  comparative  immunity  from  the  affection  is 

*  See,  for  instance,  Dalton,  op.  cit.,  and  Medical  Record,  vol.  iv.  p.  82  ;  Krom- 
bein,  Buffalo  3Ied.  and  Surg.  Journal,  June,  1864  ;  also  Epidemic  in  Iowa,  Med. 
and  Surg.  Eep,,  July  U,  1866,  and  Eistine,  Med.  Record,  1866,  vol.  i.  p.  249; 
Buck,  ib.,  1869,  vol.  iv.  ;  Hun,  Transact.  New  York  State  Med.  Soc,  1869; 
Sutton,  Transact.  Indiana  State  Med.  Soc,  1875;  Wendt,  Amer.  Journ.  Med. 
Sci.,  April,  1878;  Barton,  College  and  Clinical  Record,  Nov.  15,  1880;  Da 
Costa,  Med.  News  and  Abstract,  March,  1881  ;  Furey,  Physician  and  Sur- 
geon, Ann  Arbor,  Mich.,  1881,  iii. ;  Glazier,  Treasury  Dept  Document  No.  84, 
Marine  Hosp.,  Wash.,  1881 ;  Ranney,  Detroit  Lancet,  1881,  iv. ;  C.  E.  Persons, 
Transact.  Minnesota  Med.  Soc,  St.  Paul,  1882,  xiv.  ;  G.  B.  White,  Rep.  Amer. 
Public  Health  Assoc,  vol.  vii.,  Boston,  1883;  Smith,  ibid.;  J.  S.  Delavan, 
Med.  Ann.,  Albany,  1884,  v.  ;  B.  F.  Pope,  Phila.  Med.  News,  1884,  xliv. ;  A. 
B.  Cates,  Northwest  Lancet,  1884-5,  iv.  ;  J.  D.  Whitley,  St.  Louis  Med.  and 
Surg.  Journ.,  1885,  xlviii.  ;  A.  Abrams,  Rep.  Board  of  Health  California,  Sacra- 
mento, 1884-6,  ix.  ;  A.  C.  Kinney,  Pacific  Med.  and  Surg.  Journ.,  1887,  xxx. ; 
G.  W.  Furey,  Med.  and  Surg.  Reporter,  1887,  Ivii. ;  J.  W.  Koehn,  Med.  Reg., 
1888,  iii. ;  C.  E.  Johnston,  Month.  San.  Record,  Columbus,  1888,  i. ;  J.  H. 
Wills,  Transact.  Med.  Soc.  New  Jersey,  1888;  J.  T.  Mills,  Rep.  Board  of 
Health,  Columbus,  1889,  iii. 

t  Chicago  Medical  Examiner,  May,  1866 ;  quoted  in  Medical  and  Surgical 
Reporter,  June  2,  1866;  see  also  Billings,  New  York  Med.  .Journ.,  1883, 
xxxviii.  ;    Mary  T.  Davis,  Nashville   Journ.   Med.   and   Surg.,  1884,  N.  S., 


POISONS    AND    PARASITES.  967 

due  to  the  pork  being  much  more  generally  cooked  thoroughly 
before  it  is  eaten ;  for  the  only  prophylactic  is  thorough  cook- 
ing, prolonged  exposure  to  high  temperature  killing  the  trichinae. 
Pickling  has  little  if  any  effect.  Salting  and  smoking  are  pre- 
ventive means  of  some  value,  but  do  not  insure  safety. 


xxxiii. ;  F.  L.  James,  St.  Louis  Med.  and  Surg.  Journ.,  1884,  xlvi. ;  C. 
Du  Hadway,  Peoria  Med.  Monthly,  1885-6,  vi.  ;  J.  A.  Close,  Transact.  Internat. 
Med.  Cong.,  ix..  Wash.,  1887;  E.  L.  Mark,  Pvep.  Board  of  Health  Massa- 
chusetts, 1887-8,  Boston,  1889. 


INDEX. 


A. 

Abdomen,  abscess  in  walls  of. 561 

auscultation  of 489 

diseases  of. 481 

enlargement  of,  general 482,  640 

partial ; 648 

inflammation  of  muscles  of 550 

inspection  of.  482 

movements  of. 483 

palpation  of. 483 

percussion  of.  484 

pulsation  in 661 

retraction  of  parietes  of. 482 

rheumatism  of  walls  of. 553 

tumoi's  of 648 

Abscess,  hepatic 613 

lumbar,  confounded  with  aneu- 
rism    663 

of  abdominal  walls  confounded 

with  peritonitis 550 

of    brain    distinguished     from 

softening ..,. 211 

distinguished  from  tumor 214 

of  kidney 744 

of  larynx 247 

of  liver 599,  613 

of    thoracic    walls    confounded 

with  chronic  pleurisy 371 

perinephritic  746 

peritoneal  659 

perityphlitic 559 

psoas,  confounded   with   aneu- 
rism   663 

confounded   with    caecal   ab- 
scess   562 

pulmonary 332,  334 

retropharyngeal 246,  476 

Acephalocysts 955 

Acetone 694,  752 

Acetonuria 182 

Acidity  of  stomach  as  a  symptom.  493 

Acne 916 

rosacea 916 

Actinomycosis  hominis 947 

Addison's  disease 788 

confounded   with   chronic    dis- 
orders of  the  liver 790 


Addison's  disease  confounded 
with  discoloration  of  lacta- 
tion and  pregnancy 790 

confounded  with  fever-hues..  790 

with  hereditary  hue 790 

with  other  diseases  of  supra- 
renal capsules 791 

with  pernicious  anaemia 791 

with  phthisis 790 

with  pityriasis  versicolor...  790 

with  sun-bronzing  790 

with  syphilis 790 

with  vagrants'  disease 790 

^gophony 284 

Agraphia 56,  186 

Ague,  dumb 859 

Amhum 950 

Akataphasia ,.  186 

Albumen  in  the  urine 695 

tests  for 695-697 

Albuminuria,  simple. 722 

Alcoholism,   acute,  distinguished 

fi'om  opium  poisoning 933 

chronic 939 

Alexia 186 

Allochiria 69 

Alveolar  carcinoma 631 

Alvine  discharges  527 

Amaurosis 502 

Amblyopia 84 

Ammonisemia  distinguished  from 

uraemia 726 

Amphoric  voice 279 

Anaemia 778 

cerebral  211 

confounded  with  Bright's  dis- 
ease    728 

essential. ,  779 

idiopathic. 779 

pernicious 779 

retinal 83 

spinal 116 

Anaesthesia 65 

extended 65 

from  disease 65 

from  poisoning 65 

from  reflex  action 67 

hysterical 124 

969 


970 


INDEX. 


Anaesthesia  in  affi-etions  of  ner- 
vous centres 05 

localized G5 

muscular 09 

trii;t'miiial 07 

Anajstholics,    employment   of,   in 

feigned  aphonia 251 

Anasarca 758 

Anchylostoniiasis 950 

Aneurism,  abdominal 630,  661 

intracranial 218 

multiple,  of  renal  artery 751 

of  abdominal  aorta  confounded 

with  aortic  pulsation 603 

with  colic 540 

with  disease  of  the  spine 068 

with   lumbar   and  psoas   ab- 
scess   663 

with  neuralgia ,- 062 

with     non-aneurismal      pul- 
sating tumors 663 

with  rheumatism 662 

of      aorta      confounded      with 

chronic  laryngitis 249,  457 

of  ascending  aorta 450 

of  descending  aorta 459 

of  heart 459 

of  hepatic  artery 630 

of  innominate  artery 460 

of  pulmonary  artery 400 

phantom  461 

thoracic 450 

Angina  pectoris 396 

distinguished  from  cardiac  epi- 
lepsy   399 

from  intercostal  neuralgia 399 

from  irritability  of  heart 399 

simple  acute 465 

ulcero-membranous 470 

distinguished  from  diphtheria  470 

Animal  parasites 950 

Ankle  clonus 89 

Anthrax 946 

Aorta,  aneurism  of  abdominal..630,  661 
confounded  with  aortic  pul- 
sation   063 

with  colic  662 

with  disease  of  the  spine...  663 
with  lumbar  and  psoas  ab- 
scesses    663 

with  neuralgia  662 

with   non-aneurismal   pul- 
sating tumor 663 

with  rheumatism  662 

aneurism  f)f  thoracic 450 

confounded  with  laryngitis...  249 

coarctaticm  of 454 

constriction  of. 454 

inflammation  of 412 

malposition  of 456 


Aorta,  pulsation  of. 661,  663 

valvi's  of 442 

A  pepsia 493 

Aphasia  56,  185 

amnesic 186 

ataxic 186 

sensory 187 

Aphemia 56,  186 

Aphonia,  feigned 250 

nervous,       confounded       with 

chronic  larj-ngitis 249 

of  hysteria 249 

Aphtha' 4(i3 

distinguished  from  diidithcria...  470 

Apoplexy 173,  933 

attended  with  paralysis 174 

cerebellar 176 

confounded  with  acute   soften- 
ing   182 

with  asphyxia 182 

with  catalepsy 190 

with  cerebral  hysteria 184 

with  diabetic  coma 181 

with  epilepsy 178 

with  insensibility  from  drink.  180 
with  insensibility  from    nar- 
cotics   180 

with  meningitis 178 

with  obstruction  of  the  cere- 
bral arteries 178 

with  protracted  sleep 183 

with  sudden  extensive  paral- 
ysis   183 

with  sun-stroke  188 

with  syncope 182 

with  tumors 179 

with  urasmic  coma 181 

hemorrhage  a  cause  of 175 

cerebral 177 

seat  of 175 

pulmonary 347 

mistaken     for    acute    pneu- 
monia    347 

serous '.  175 

spinal Ill 

Appendix  cajci,  diseases  of. 556 

perforation  of 558 

Appetite,  loss  of,  as  a  symptom...  492 

Arcus  senilis 431 

Argvll-Robertson  pupil 142,  145 

Army  itch 923 

Arteries,  cerebral,  obstructions  of, 

confounded  with  apoplexy.  178 

coagulation  in 797 

diseases  of 763 

inflammation  of  coats  of... 450, 

792,  800 

Arteritis 763 

acute 765,  808 

general 764 


INDEX. 


971 


Arthritis,  rheumutic 815 

Ascaris  lumbrici)ide-? 951 

mystax 952 

Ascites 040 

confounded  with  cancer  of  peri- 
toneum   645 

with  chronic  peritonitis 644 

with  chronic  tympanitis 646 

with  distention  of  the  blad- 
der    646 

with  gravid  uterus 646 

with  ovarian  dropsy 641 

Asphyxia  distinguished  from  apo- 
plexy   182 

local , 767 

Asthma 2!i0 

cardiac 292 

diagnosticated  from  croup 291 

from  oedema  of  the  glottis 291 

from  pressure  of  tumors 292 

dyspnoea  in 290 

hay 306 

in  Bright's  disease 730 

Ataxia,     progressive     locomotor, 

142,  145 
distinguished   from   diseases  of 

.the  spinal  cord 145 

Friedreich's 144 

Atheromatous  changes  in  vessels..  765 

Athetosis 199 

Atrophy  of  liver,  acute   yellow, 

603,  607 

chronic 639 

of  optic  nerve 88 

of  spinal  cord 119 

progressive  muscular 133 

Auscultation  269 

immediate 270 

mediate 270 

of  abdominal  viscera 489 

of  children 287 

of  the  voice 284 

B. 

BelPs  palsy 128 

Beriberi 136,  761 

Bile  in  the  urine 689 

Bilharzia  hsematobia 705 

Biliary  abscesses 615 

acid 691 

Pettenkofer's  test  for 691 

passages,  inflammation  of 603 

confounded  with  acute  hep- 
atitis   603 

fever  in 606 

Bilious  attack 511 

remittent  fever 884 

Bladder,    distended,    confounded 

with  ascites 646 


Bladder,    distended,    confounded 

with  peritonitis 549 

hemorrhage  from 701 

inflammation  of. 743 

confounded  with  peritonitis...  549 

neuralgia  of. 743 

spasm  of,  confounded  with  colic  537 

Blood,  air  in 800 

diseases  of 768 

Blood-casts 719 

Blood-globule-counting 769 

Blood-vessels,  diseases  of 763 

Body,  position  of,  as  a  symptom..     30 

Bowels,  hemorrhage  from 582 

morbid  discharges  from 575 

Brain,  abscess  of 211 

anaemia  of 211 

and  spinal    cord,  table  of  dis- 
orders of 158 

atrophy  of. 212 

congestion  of. , 210 

diseases  of 52 

headache  as  a  symptom  of.. .70,  71 

dropsy  of 166 

hemorrhage  into 210 

hypertrophy  of. 221 

distinguished    from   enlarge- 
ment of  the  head 222 

inflammation  of 213 

confounded  with  pericarditis.  420 

with  remittent  fever 866 

lesions  of  gray  central  ganglia..  104 

localization  of  function  of 103 

meningitis  of  base  of. 160 

softening  of ..209,  213 

syphilis  of 126,  862 

table  of  diseases  of. 158 

tumor  of 213 

distinguished  from  abscess....  214 

from  softening 214 

Brain-power,  exhaustion  of. 212 

Breathing.     See  Respiration. 

Breath -sound,  metamorphosing...  279 

Bright's  disease,  acute 718 

confounded    with    acute   ne- 
phritis   721 

with  coma 724 

with  convulsions 724 

with  dropsy 724 

with  hasmaturia 722 

with  pericarditis 724 

with  pleurisy 724 

with  pulmonary  oedema 723 

with  purulent  urine ,  722 

with  simple  albuminuria...  722 
with  suppurative  nephritis.  721 

chronic 726 

confounded  with  anaemia 728 

with  asthma. 730 

with  cancer 731 


972 


INDEX. 


Bright's    disease,    chronic,    con- 
founded     with     cardiac 

dropsy 730 

witli  chronic  hronchitis 730 

with"  chronic    consecutive 

Tiopliritis 733 

witli  I'hronic  rlicuniutism...   730 

with  cysts  of  kidney 731 

with  gastro-intestinal    dis- 
orders   731 

witli  neuralgia 7-9 

with  renal  inadequacy 734 

with  tuhercle 731 

nervous  symptoms  in 729 

retinitis  in 83 

table  of  clinical  diti'erences  in...   740 
Bronchial  glands,  tuberculization 

of 296 

phthisis 29(3 

distinguished  from  hooping- 
cough .^.  29G 

Bronchitis";  acute. ...301,  339,  348,  893 
diagnosticated  from  capillary 

bronchitis 303 

from  consumption,  acute...  302 

from  hooping-cough 295 

from  pneumonia 302 

from  tuberculosis 302 

of    large    and     middle-sized 

tubes 301 

physical  signs  of 295 

sputa  in 301 

capillary 303 

confounded  with  acute  lobar 

pneumonia  304 

with  acute  miliary  tuber- 
culosis   339 

with  broncho-pneumonia...  304 

with  phthisis 303 

chronic 305 

confounded  with  Bright's  dis- 
ease    730 

with  nasal  catarrh 306 

with  phthisis 323 

of  the  finer  tubes 339 

plastic 306 

putrid 307 

sputa  in 305 

Bronchophony 284 

Broncho-pneumonia 301,  312,  339 

mistaken  for  collapse 311,  312 

Bronchorrhcea 305 

Bruit  de  moulin 422 

Bulbar  paralysis 131 

Bullous  diseases 915 

C. 

Caecum,  affections  of 556,  573 

appendix  of,  diseases  of. 55G,  573 


Ca'cum,  cancer  of 560 

distention  of 560 

inflammation  of 55(5 

Calcium  oxalate 08*) 

Calculi,  renal 713 

irritation  of 749 

of  the  pancreas 652 

Cancer  of  civcuin 560 

of  gall-bladder., 626 

of  intestine 660 

of    kidney     confounded     with 

Bright's  disease 731 

of  liverT 620 

confounded  with  acute  con- 
gestion   623 

with  acute  hepatitis 623 

with  cancer  of  oineiitum...  627 

with  cancer  of  stomach 626 

with  chronic  congestion....   623 
with  disease   of  gall-blad- 
der   625 

with  enlarged  kidney 627 

with  fatty  liver  '. 623 

with  syphilitic  liver  624 

with  waxy  liver 623 

of  lungs 329,  373 

confounded      with      chronic 

pk^urisy 369,  373 

with  phthisis .329 

of  lymphatic  glands 787 

of  lymphatic  glands  lying    by 

side  of  vertebrae 657 

of  omentum 525 

confounded   with    cancer   of 

liver 627 

of  pancreas 651 

of  peritoneum 645,  659 

of  pleura 369 

of  stomach 518,  638 

confounded    with    cancer    of 

liver 626,  638 

with  chronic  gastritis. ..514,  521 

with  gastric  ulcer 514,  521 

of  the  tongue 465 

Cancrum  oris 463 

Capillaries,  diseases  of. 766 

Carditis 423 

Catalepsv     accompanying     hys- 
teria  ■; '....  190 

associated  with  hypnotism 191 

confounded  with  apoplexy 190 

with  ecstasy 191 

daymare  form  of 191 

feigned 191 

Catarrh,  gastric 510,  512,  929 

in  measles 892 

nasal 306 

sutlocative 295 

Catarrhal  fever  confounded  with 

hay  fever 824 


INDEX, 


973 


Cavernous  voice  284 

Central  ganglia,  gray,  lesions  of...  104 

Cerebellum,  diseases  of 147 

Cerebral  affections,  table  of 158 

pain    in,   distinguished    from 

hemicrania 227 

localization 52 

Cerebritis  confounded  with  men- 
ingitis   161 

Cerebro-spinal  disorders 145 

fever 847 

confounded   vrith   congestive 

fever 851 

with  inflammation  of  cord.  851 

with  malignant  measles 852 

with  pneumonia 852 

with   rheumatism   of    cer- 
vical muscles 852 

with  scarlatina 851 

with      sporadic      cerebro- 
spinal meningitis 851 

with  tetanus 851 

with  tubercular  meningitis  851 

with  t\'phoid  fever  850 

with  typhus  fever 852 

with  ursemia 852 

Cestoidea 951 

Charbon 946 

Charcot's  disease 149 

Chest,    alterations    of  form,  size, 

etc.,  of,  in  disease 259 

dilatation  of,   diseases  present- 
ing   360 

diseases  of 256 

mapping   out   of,   for   physical 

diagnosis 257 

mensuration  of..... 259 

motions  of,  in  diseases  of 259 

retraction  of,  diseases  attended 

with 372 

Cheyne-Stokes  respiration 293,  431 

Chickahominy  fever 879 

Chicken-pox 901 

Childbed  fever 546 

Children,  auscultation  of. 287 

respiration  in 287 

Chloasma  919 

Chlorides  in  the  urine 683 

Chlorosis 778,  796 

confounded      with      pernicious 

anaemia 783 

Choked  disk 83,  217 

Cholera 587,  929 

Asiatic,  confounded  with   yel- 
low fever 884 

infantum 585 

morbus 586,  591 

distinguished     from    irritant 

poisoning 591,  929 

Chorea 196 


Chorea  attended  with  salaam  con- 
vulsions   200 

Chorea  caused  by  eye-strain. ..197,   198 

distinguished  from  athetosis 190 

from  cereljro-spinal  sclerosis..   199 

from  convulsive  tremor 199 

from  epilepsy 198 

from  facial  spasm 200 

from  hysteria 201 

from  paralysis  agitans 198 

from  spasms  of  acute  cerebral 

disease 198 

from  tetanus 198 

from  writer's  cramp  200 

paralytic 198 

post-hemiplegic 200 

post-paralytic 106 

relations  of,  to  rheumatism 197 

Choroid  coat,  inflammation  of 84 

tubercles  of... 84 

Chylous  urine 709 

Circulation,  derangements  of,  in 

cardiac  disease 394 

paralysis      from       iiiterference 

with 92 

Cirrhosis  of  liver 633 

confounded    with    cancer    of 

stomach 638 

with  chronic  peritonitis  . ...   638 

hypertrophic 635 

of  lung  confounded  with  chron- 
ic pleurisy 374 

Clots,  fibrinous,  in  the  heart 412 

Coftee-ground  vomit 501,  520 

Colic 530 

as  a  symptom 530 

bilious. 531 

confounded     with     abdominal 

aneurism 540,  662 

with  abdominal  neuralgia 539 

with  enteritis 540 

with  gall-stones  535 

with  gastralgia 534 

with  hepatic  neuralgia 535 

with  hernia 534 

with  nephralgia 536 

with  neuralgia  of  dorsal  and 

lumbar  nerves 539 

with  perforation  of  the  intes- 
tine     534 

with  peritonitis 540,  554 

with  spasm  of  the  bladder...  537 

with  spinal  disease 540 

with  tumors 540 

with  uterine  colic 538 

copper 532 

flatulent 531 

from  disease  of  the  bowel 533 

lead 532 

malarial 532 


974 


I^'DEX. 


Colic,  metallio 532 

nervous 532 

spasmodic- 530 

uterine... 588 

Collapse  of  the  lun£j 311 

fonfounded       with      ehronic 

pleurisy.  375 

Colon,  dilatation  of 6(i0 

percussion  o{ 48i> 

Coma  ^>1 

occurring  in  Bright's  disease...  724 

uriemic 181,  725 

Coma-vigil 841 

Congestion,  hypostatic 340 

of    brain     discriminated    from 

softening 210 

pulmonary 346 

Congestive  fever 872 

algid 873 

cerebral 873 

confounded  with  cerebro-spinal 

fever 851 

gastro-enteric 872 

thoracic  873 

Consciousness,    diseases     marked 

by  sudden  loss  of. 173 

Constipation  as  a  symptom 578 

from  michanical  changes 575 

habitual 573 

Consumption.     See  Phthisis. 

galloping 338 

Cc>nvulsions 152 

See  also  Spasms. 

diseases  marked  by 191 

distinguished  from  epilepsy 195 

ill  Bright's  disease 724 

in  tvpht)id 831 

salaam 200 

urremic 725 

Cord.     See  Spinal  Cord. 

Cough... 294 

from  nasal  affections 306 

in  laryngeal  afiections 231 

Countenance,  expression  of,  as  a 

symptom 31 

Crackling  in  tubercle  of  lungs...  282 

Cramp  of  stomach 603 

writer's 200 

Cranial  reflexes 88 

Crepitation 281 

Croup  241 

cataiThal  241 

confounded     with     abscess    of 

larynx 247 

with  diphtheria 24fi 

with  laryngitis.  245 

with      retropharyngeal     ab- 
scesses   246 

with  secondary  laryngitis  of 
the  exanthemata 245 


Croup,  diseases  conf  mnded  with, 

245,  247 

Croup,  talse 241,  244 

membranous,  confounded  Avith 

diphtheria 240,  472 

membranous,         distinguished 

from  acute  laryngitis 245 

from  diphtheria 246 

from  oedema  of  the  glottis 245 

from  retrolaryngeal  abscesses  246 
from     retropharyngeal      ab- 
scesses   246 

from  scarlet  fever 891 

spasm  of  glottis  in 242 

true 243 

Crustu  lactea 913 

Cysticercus  cellulosie 952 

Cystine ,  714 

Cystitis,  acute 743 

confounded   with    acute    ne- 

•phritis 743 

with  metritis 743 

with  neuralgia 743 

with  peritonitis 549 

chronic 744 

Cysts  of  kidnej's 731 

confounded  with  hydronephro- 
sis   750 

D. 

Davmare 191 

Dead  lingers 767 

Debilitv  confounded  with  typhoid 

fever 835 

Deep  reflexes 88 

Delirium 58 

accompanying  insomnia 62 

active ". 59 

confounded  with  delirium  tre- 
mens   171 

fierce 59 

hysterical 61 

in  typhoid 831 

mistaken  for  insanity 59 

of  inanition 60 

prominent  as  a  symptom,  acute 

afiections  with 159 

quiet 58 

simulated 61 

tremens : 169 

confounded  with  acute  mania  172 

with  acute  meningitis 170 

urremic 725 

Dengue 891,  902 

diseases  distinguished  from 904 

Dermatitis  medicamentosa 918 

Diabetes 751 

distinguished       from      chronic 

polyuria 755 


INDEX. 


975 


Diabetes  insipidus 754 

with  coexisting  albuminuria....   754 

Diacetic  acid     694 

Diagnosis  by  exclusion 23 

differential 22 

meth(;ds  of  arriving  at 21 

physical 256 

sources  of  error  in 24 

Diaphragm 292 

fatty  degeneration  of 293 

inflammation  of 293 

paralysis  of 292 

rheumatism  of 293 

Diarrhoea 576 

acute 576 

bilious 576 

choleraic 588 

chronic 577 

fatty 584 

intermittent 579 

in  typhoid  fever 829 

membranous 579 

of  dissecting-room 948 

of  soldiers 577 

strumous,  of  children 579 

tubercular  578 

Digestive  troubles 592 

Dilatation,  bronchial,  confounded 

with  phthisis 831 

with  pulmonary  abscess 333 

with  pulmonary  gangrene.  335 

of  heart 428 

confounded  with  fatty  degen- 
eration   430 

with  pericardial  effusion...  434 

Diphtheria 467 

catarrhal 469 

confounded  with  aphthce 470 

with  croup ,  472 

with  erysipelas  of  the  fauces.  471 
with  gangrene  of  the  mouth.  470 
with  pharyngitis  and  tonsil- 
litis    469 

with  scarlatina 473 

with  thrush 470 

with  ulcerative  stomatitis 470 

with  ulcero-membranous  an- 
gina    470 

croupous 467 

intercurrent 473 

laryngeal 472 

confounded  with  scarlet  fever  891 

nasal 473 

paralysis  in 126 

Discharges,  alvine. 527 

as  a  symptom 527 

Displacements  of  heart 449 

Distoma  hepaticum 955 

Diuresis,  chronic    754 

in  hysterical  women 755 


Dochmius  duodenalis 956 

Dracunculus 956 

Drink,  insensibility  from 180 

Dropsy 758 

abdcmiinal 640 

acute 762 

cardiac. 394,  760 

causes  of 760 

chronic  762 

dependent  upon  a  tumor 759 

fi'om  antemia 759 

from  malarial  poisoning 759 

from  scarlet  fever 889 

general 760 

from  irritation  of  areolar  tis- 
sue     761 

from      peripheral      multiple 

neuritis  761 

hepatic 761 

internal 759 

of  brain 220 

ovarian 641 

pericardial 434 

confounded  with  cardiac  dila- 
tation   434 

renal 760 

Duodenum,  catarrh  of 543 

ulcer  of. , 517 

Dysentery 579 

acute 579 

chronic 582 

confounded  Avith  piles 581 

with  proctitis  581 

distinguished  from  diarrhoea 581 

from  enteritis 581 

Dyspepsia  as  a  symptom ,  507 

atonic 507 

Dysphagia 480 

Dyspnoea 289 

caused  by  aneurismal  tumor....  292 

by  goitre 292 

from  cervical  glands 292 

from      disease      of      the     dia- 
phragm  292,  293 

in  asthma 290 


E. 

Echinococci..  954 

Ecstasy 191 

distinguished  from  catalepsy....  191 

Ecthyma ". 916 

Eczema 912 

diseases  confounded  with 914 

impetiginodes 913 

rubrum 913 

squamosum  918,  918 

Effusions,  pericardial 434 


976 


INDEX. 


Eifusions,  pk'ural 355,  3f)6 

Electricity  in  paralysis 95 

faradaic  UT 

galvanic ^>7 

static 'J8 

Electro-muscular  sensibility 98 

Elephantiasis  of  the  Arahs 921 

Emaciation  as  a  symptom 31 

Embolism 411,  795,  797 

from  accunuilations  of  pigment 

in  the  blood 800 

from  acute  endarteritis  800 

of  cerebral  arteries 798 

of  pulmonary  artery 79() 

of  I'enal  artery 798 

of  vessels  of  liver 798 

splenic 798 

Emphysema 291,  308,  323 

and  "tubercle ; 323 

confounded  with  chronic  pleu- 
risy    3G8 

diagnosticated    from    pneumo- 
thorax  310,  361 

interlobular 310 

Empyema,  pulsating,  confounded 

with  aneurism 454 

Endarteritis 764 

Endocardial  murmurs 387,  408 

Endocarditis,  acute 408 

confounded  with  pericarditis.  418 

ulcerative 413 

head  -  symptoms  of,  con- 
founded with  acute  men- 
ingitis      164 

confounded   with    tvphoid 

fever .' 837 

Engorgements,      pulmonarv,     in 

fevers  '. 346 

mistaken  for  acute  pneumo- 
nia   346 

Enteritis 540 

acute 540 

confounded  with  colic 540 

with  peritonitis 548 

with  typhoid  fever 836 

muco- 542 

Ephelides ....  919 

Epidemic  meningitis 847 

Epigastrium,  tumors  of 651 

Epiglottis,  swelling  of 240,  251 

Epilepsy 191 

aura  preceding 192 

cardiac 399 

central  or  centric 193 

distinguished  from  apoplexy....   195 

fr()m  chorea  198 

from  convulsions 195 

from  hysteria 195,  201 

eccentric 194 

feigned 196 


Ejiilepsy  followed  by  hemiplegia.  193 

idiopath  ic 1 94 

Jacksonian 195 

minor 192 

peripheral 193 

sequelae  of 193 

symptomatic 194 

.syphilitic 195 

vertigo  previous  to 75 

Epiphvtes  923 

Epistaxis 298 

Eructation  as  a  symptom 495 

Eruption  in  measles 892 

Erysipelas 904,  922 

confounded  with  mumps 906 

diseases  distinguished  from 905 

migrans 906 

of  the  fauces  confounded  with 

diphtheria 471 

Erythema 905,  909 

desquamative 910 

intertrigo 910 

Examination  of  patients,  methods 

of 27 

analytical  27 

by  anamnesis 27 

.synthetical 27 

Exanthematous  fevers  886,  905 

Excitation  of  muscles 95 

direct 95 

indirect 95 

Exhalations,  poisonous 948 

Eve,  abnormal  changes  in  fundus 

of 82 

abnormalities  of  pupils  of. 81 

appearance  of,  in  disease 76 

conjugate  lateral  deviation  of...  80 

derangements  of  mechanism  of.  76 

embolism  of 83 

external  abnormalities  of 78 

hypera?mia  of 83 

idiopathic  derangements  of 76 

paralysis  of  accommodation  of.  82 

ptosis  of. 81 

reflex  neuroses  of. 84 

sixth  nerve  of,  affections  of 80 

strain  of 77 

subjective  visual  derangements 

of 84 

third  nerve  of,  affections  of 80 

Eye-strain 77 

as  a  cause  of  chorea 197,  198 

F. 

Face,  spasm  of. 226 

Facial  palsy 128 

Fffical  discharges 527 

Faeces,  accumulation  of. 650 


INDEX. 


977 


Farcy,   acute,    confounded    with 

pysemia 792 

Fat  in  urine 708 

Fatty  degeneration  of  heart 430 

confounded  with  chills  482 

with  dilatation 431 

Fauces,  diseases  of 465 

erysipelas  of 471 

inflammation  of. 465 

ulcers  of,  syphilitic 476 

Favus ." 924 

Feigned  aphonia 250 

delirium 61 

diseases 23 

epilepsy 196 

hysteria 203 

rheumatism 812 

sciatica 229 

Fever,  bilious  typhoid 855 

catarrhal 823 

cerebro-spinal.. 847 

Chickahominy 879 

congestive  872 

enteric 825 

eruptive 886 

hectic 860 

hemorrhagic  malarial 875 

hepatic 606 

icterode  pernicious 875 

infantile  remittent 871 

intermittent 858 

malario-tj'phoid 880 

miasmatic 858 

miliary 894 

nervous 831 

pharyngeal 906 

puerperal  malarial 862 

relapsing 854 

remittent 863 

scarlet 886 

simple  continued 822 

spotted 847 

syphilitic 862 

typhoid 825 

typho-malarial 866,  877 

typhus 839 

urethral 861 

yellow 876,  880 

Fevers 820 

classification  of. 821 

continued 821 

head-symptoms       of,       con- 
founded with  meningitis...  161 

eruptive 886 

exanthematous.. 886,  905 

periodical 857 

pulmonary  engorgement  in 346 

type  of. 821 

Fibrin,  clots  of,  in  the  heart 412 

in  the  urine 709 


Fifth   nerve,   painful   ana3Sthesia 

of 225 

Filaria  medinensis 956 

sanguinis  hominis 955 

Flatulency  as  a  symptom 494 

Follicular  tonsillitis 469 

Foot  and  mouth  disease 947 

Fremitus,  friction 262 

pleural 285 

rhonchal 262 

vocal 262 

French  measles 895 

Friction,  pericardial 392 

pleural 282 

Fungus  foot  of  India 949 


G. 

Gall-bladder,  cancer  of 626 

diseases  of. 615,  625 

confounded   with    cancer   of 

liver 625 

distention  of. 630 

inflammation  of. 604 

Gall-ducts,  inflammation  of. 604 

Gall-stones,  passage  of,  con- 
founded with  cancer  of  the 

liver 626 

confounded  with  colic 535 

with  fgecal  accumulations..  536 

with  intermittent  fever 861 

Gangrene  associated  with  paraly- 
sis      92 

of  the  mouth 464 

confounded  with  diphtheria..  470 
pulmonary,    confounded    Avith 

phthisis 334 

symmetrical 767 

Gastralgia 503 

confounded  with  colic 534 

Gastritis,  acute 508 

distinguished    from    gastritis 

by  poisoning 929 

chronic 512 

confounded  with  gastric  can- 
cer  518,  521 

with  gastric  ulcer 514,  621 

with  hepatic  congestion....  611 

with  peritonitis 548 

of  jroung  children 511 

Gastrodynia 503 

confounded  with  colic  534 

Gastro-intestinal  disorders  con- 
founded with  Bright's  dis- 
ease    731 

Gastroxynsis 494 

German  measles 895 

Girdle  pain 118 


62 


978 


INDEX. 


Glanders,  acute,  confounded  with 

pyaMiiia 792 

Glossoplet^iii 108 

Glottis,  oeijema  of 240 

spasm  of. 242 

Glycosuria 754 

Goitre,  exophtluilmii' 403 

Gout 804,  812 

rheumatic 81 ') 

Gravel 078 

Guinea-worm 95G 


H. 

Habit-chorea 198 

Habit-spasm I'-'S 

Ha'Uiatemesis 501 

Ha^iiatiuuria,  intermittent 875 

paroxysmal 703 

Hiematocele,  retro-uterine 658 

Hajmatoma 177 

Hicmaturia 699 

•    confounded  with  acute  Bright's 

disease 722 

intermittent 70o 

malarial 704,  875 

renal 702 

tubal 705 

vesical 705 

Haemoglobin 774 

H;emoglobinuria 703,  705 

Hiemophilia    distinguished    from 

purpura  803 

Haemoptysis —  297 

Hay  asthma 306 

HaV  fever 306,  824 

Head,    enlargement    of,    diseases 

characterized  by 220,  222 

shapes  of,  in  disease 221 

Headache - 70 

congesti  ve 71 

from  astigmatism 75 

from  poisoning 72 

in  diseases  of  the  brain 70 

nervous 71 

neuralgic 71 

sick 71,  226 

sympathetic 72 

urfemic  729 

Hearing,   sense   of,   derangement 

of 86 

Heart,   anatomv   and  phrsiology 

of r. I .'.  376 

aneurism  of 459 

atrophy  of 406,  733 

auscultation  of. 383 

cavities     of,    accumulation     of 

blood  in 434 


Heart,  chronic  diseases  of,  with  in- 
creased percussion  dulness    424 

clots  of  tibrin  in 411,  412 

dilatation  of, 406,  428 

diseases  of 376,  435 

confounded  with  intermittent 

fever 861 

with  pernicious  anjEmia...   783 

.symptoms  of. 393 

disj)lacL'ments  of,  diseases  pre- 
senting   360,  449 

dropsy  caused  by  disease  of ....  394 
enlargement  of,  symptoms  of...  435 

examination  of. 379 

fatty  accumulation  on 433 

fatty  degeneration  of. 430 

functional  disorders  ()f. 401 

gouty 427 

iiemisvstole  of 403 

hypertrophy  of, 406,  425 

impulse  of. 379 

intiammation  of. 423 

inspection  of. 379 

irregularity  of  action  of 403 

irritable...'. 404 

malformations  of. 435 

mitral  disease  of. 441 

murmurs 387,  435 

organic  diseases  of. 406 

pain  in  region  of. 399 

palpation  of. 380 

palpitation  of 400 

percussion  of 381 

percussion  dulness  of,  increased  424 

rupture  of. 433,  448 

slow  action  of. 401 

starvation 432 

strain 406 

valvular  affections  of. 435 

table  of. 443 

Heart-burn 494 

Heat  exhaustion 190 

Hectic  fever  distinguished   from 

intermittent  fever 860 

Heller's  test 696 

Hemianopsia 85,   108 

bilateral 104 

Hemicrania 226 

distinguished  from  pain  of  or- 
ganic cerebral  affections...  227 

from  periostitis 227 

from     rheumatism     of     the 

scalp 227 

Hemiplegia 100 

alternating 100 

anatomical  diagnosis  of 102 

appearance  of  muscles  in 105 

cerebral 101 

corpus  striatum  in 102 

cortical  104 


INDEX. 


079 


Hemiplegia,  electricity  as  a  test 

of. 101,  106 

feigned 106 

following  epilepsy 193 

lesions  of  capsule 104 

of  crus  cerebri 103 

of  pf)ns  Varolii 102 

hysterical 124 

nature  of  lesions  in 105 

optic  thalamus  in 102 

pathological  diagnosis  of 105 

right-sided,  associated  with  loss 

of  articulate  language 185 

rigidity  in 105 

seat  of  lesion  in 100 

spinal , 101 

Hemorrhage     a    cause    of    apo- 
plexy    173 

between  the  membranes  of  the 

brain 177 

cerebellar 176 

cerebral 177 

cortical 177 

from  aneurism 299 

from  the  bladder 701 

from  the  intestines 582 

from  the  kidneys... 701 

from  the  larynx,  trachea,  etc 298 

from  the  lungs  299 

from  the  cesophagus 298 

from  the  oral  cavity 298 

from  the  prostate  gland 706 

from  the  stomach    298 

distinguished     from    irritant 

poisoning 929 

from  the  urethra 706 

from  the  ventricles  of  the  brain.  176 

in  apoplexy,  seat  of. 175 

into  the  anterior  lobe 176 

into  the  corpora  quadrigemina..  176 

into  the  pons 176 

into  the  subarachnoid  spaces....   177 

into  the  thalamus  176 

limited  to  the  arachnoid 177 

of  the  bowels 582 

relations  of,  to  softening  of  the 

brain..  210 

spinal Ill 

vicarious 501 

Hemorrhagic  malarial  fever 875 

confounded  with  intermittent 

hsematinuria 875 

with  yellow  fever 876 

Hemorrhoids 583 

Hepatic    diseases,     chronic     and 

acute,  confounded 601 

fever 606 

confounded  with  intermittent 

fever 861 

Hepatitis,  acute 598 


Hepatitis,  acute,  confounded  with 

acute  infectious  jaundice  603 
with  acute  non-hepatic  dis- 
eases    601 

with  acute  yellow  atrophy.  603 

with  cancer  of  liver 623 

with  chronic  hepatic  dis- 
ease with  acute  symp- 
toms   601 

with  diaphragmatic  pleu- 
risy   602 

with  inflammation   of  the 

biliary  passages 603 

with  inflammation    of  the 

portal  veins 600 

with  perihepatitis  599 

with  pigment  liver 600 

chronic 612 

interstitial 635 

Hernia,  diaphragmatic,  con- 
founded with  pneumo- 
thorax     364 

strangulated,   confounded  with 

colic 534 

with  intestinal  obstruction....  564 

with  irritant  poisoning  929 

through  the  recti  muscles 617 

Herpes    914 

labialis 914 

zoster  914 

Hiccough  in  diaphragmatic  pleu- 
risy   602 

Hip-joint    affections    confounded 

with  sciatica 228 

Hodgkin's  disease 786 

confounded      with      lymphatic 

cancer 787 

Hooping-cough 294 

diagnosticated  from  acute  bron- 
chitis   295 

from  bronchial  phthisis. 296 

Hydatids  of  the  liver 614 

Hydroa 915 

Hydrocephaloid  disease 166 

Hydrocephalus,  acute 166 

chronic 166,  220 

Hydronephrosis  750,  755 

confounded  with  hydatid  tumor 

of  kidney 750 

with  renal  cysts 750 

Hydrophobia     confounded     with 

tetanus 207 

Hydrothorax     confounded     with 

chronic  pleurisy 371 

Hyperemia  of  the  disk 83 

Hypersesthesia 63 

general 64 

hysteria  as  a  cause  of 64 

one-sided 64 

relations  of,  to  inflammation....     63 


980 


INDEX. 


Hypertrophy  of  brain 221 

enlargompnt    of    heiul     con- 
founded wilh 222 

of  heart 425 

of  skin U21 

Hypochondriuni,  tumors  of (148 

Hyposjastric  res^ion,  tumors  of HSS 

Hysteria 200 

abdominal,     coiifouiuled     witli 

]ieritonitis 553 

with  tubercular  meningitis...   1<j8 

as  a  cause  of  hypera^sthesia  ()4 

associated  with  catalepsy 190 

cerebral,     distinguished      from 

apoplexy 184 

distinguished  from  chorea 201 

from  epilepsy 201 

ft>igned..; .*. 203 

resembling  locomotor  ataxia 14G 

Hysterical  complaints,  local 203 

delirium Gl 

hydr,.pho])ia 208 

locomotor  ataxia 147 

paralysis  01 

pseudo-maladies 203 

tetanus 205 

Hystero-epilepsy 202 

I. 

Ichthyosis  918 

Icterode  pernicious  fever 875 

Icterus 596 

catarrhalis 604 

distinguished      from      acute 

atrophy  of  liver 606 

from  biliary  calculi 606 

fr>im  cancer  of  liver 605 

from  cirrho.sis 605 

fi'om  congestion  of  liver 605 

from  hepatic  inflammation.  605 

neonatorum  596 

Iliac  fossa,  diseases  attended  with 

pain  in 556 

region,  tumor  of. 657 

Impetigo 916 

Inflammation,   local,   confounded 

with  neuralgia 223 

Influenza ^ 823 

Innominate,  aneurism  of 460 

Inosite 694 

Insanity  confounded  with  delir- 
ium       59 

Insensibility   from   drink   distin- 
guished from  apoplexy 180 

from     narcotics     distinguished 

from  apoplexy 180 

Insolatio.     See  Sun-stroke. 
Insomnia 62 


Insomnia  with  delirium 62 

Inspection  in  diagnosis 258 

Insuflicieiicy     of     aortic     valves 

confounded  with  aneurism.  453 

Intellection,  deranged 58 

Intermittent  fever 858 

distinguished  from  diseases  of 

the  heart 861 

from  hectic  fever 860 

from  hepatic  fever 861 

from  remittent  fever 865 

from  syphilitic  fever 862 

from  urethral  fever 861 

Intestinal  worms 951 

Intestines,  cancer  of. 660 

contraction  in 570 

dilatation  of 527 

confounded  with  dilatation  of 

stomach 527 

disease  of 527 

hemorrhage  of 582 

inflammatitin  of 556 

internal  strangulation  of 572 

invagination  of 561,  568 

obstruction  of 563,  569 

confounded  with  peritonitis...  564 
with  strangulated  hernia...  564 

from  stricture 570 

from  volvulus 569 

location  of  lesion  in 571 

percussion  of 487,  489 

perforation  of,  confounded  with 

colic 534 

spasmodic  contraction  of 567 

Intoxication,  ura?mic 724 

Intra-hepatic  concretion 861 

Iris-contraction 88 

Itch,  army 923 

J. 

Jaundice 592,  632 

acute  infectious 603 

catarrhal 623 

diagnosis  of 593 

of  the  new-born 596 

K. 

Kakke 136 

Kidney,  abscess  around 561 

abscess  of. 561,  744 

distinguished  from  cystitis....  745 

aflections  of. 525 

calculus  in 717 

cancer  of 731 

contracted 738,  755 

confounded   with   pernicious 

ana3rnia 783 


INDEX. 


981 


Kidney,  cysts  of. 733 

enlarged,  chronically  inflamed.  735 
confounded    with    cancer    of 

liver 627 

with  hydatids  of  liver 631 

with  ovarian  tumor 657 

fatty •... 784 

hemorrhage  from 701 

hydatids  of 750 

"confounded    with     hydrone- 
phrosis   750 

inflammation  of 712 

pelvis  of. 749 

movable 654 

neuralgia  of 714 

pain  in 713 

confounded  with  colic 533 

paroxysmal 714 

persistent 716 

percussion  of 487 

sarcoma  of 732 

suppurative  inflammation  of....  746 

surgical 734 

syphilomata  of 732 

tubercle  of. 732 

confounded     with      Bright's 

disease  732 

tumors  of 561 

waxy 736 

Knee-jerk 89 

Kreatin  685 

Kreatinin 685 


L. 

Landry's  paralysis 112 

Laryngeal  afi'ections,  acute 238 

phthisis 252 

rheumatism 240 

stenosis 253 

stridor 230 

vertigo 75 

Laryngismus  stridulus 237,  242 

Laryngitis,  acute 238 

confounded  with  croup... 239,  241 
distinguished  from  acute  pul- 
monary aflPections  238 

from  pharyngitis 239 

from  tonsillitis 239 

chronic 248 

aneurism  of  aorta  confounded 

with 249 

combined  with  syphilis 248 

with  tuberculosis 248 

confounded      with       altered 

voice 249 

confounded  with  aneurism...  457 

with  hysterical  aphonia....  249 

with  nervous  aphonia 249 


Laryngitis,  difi"use  cellular 230 

diseases  confounded  with 249 

feigned 250 

hemorrhagic  239 

(Edematous 240 

secondary,  of  the  exanthemata.  245 

spasmodic 244 

Laryngoscopy 231 ,  235 

Larynx,  abscess  of. 247 

acute  diseases  of. 238 

affections  of  nerves  of 250 

cancer  of 253 

changes  in    breathing    in   dis- 
eases of 230 

in  voice  in  diseases  of. 230 

chronic  diseases  of. 248 

cough  in  diseases  of 231 

diseases  of. 230 

inflammation  of. 239 

organic  diseases  of 237 

pain  in  diseases  of 231 

polypi  in 253 

stenosis  of. 253 

table  of  diseases  of. 237 

tumors  of. 253 

ulcers  in 253 

Lead  poisoning 942 

paralysis  from 125,  942 

Lentigo 919 

Lepra 920 

Leucine 688 

Leuksemia 784 

distinguished    from   pernicious 

aneemia ,.  784 

lymphatic 784 

myelogenous 784 

pseudo-leukjemia  distinguished 

from ': 787 

splenic 784 

Lichen 911,  918 

ruber 911 

scrofulosorum 911 

Lithsemia 814 

Liver,  abscess  of. 613,  629 

diseases  confounded  with 614 

actinomycosis  of. 614 

acute  affections  of. 607,  636 

confounded  Avith  pyaemia 793 

congestion  of. 598,  623 

confounded  with  cancer  of 

liver 623 

with  remittent  fever 866 

inflammation  of 598,  608,  623 

distinguished    from   catar- 
rhal icterus 605 

yellow  atrophy  of. 603,  607 

confounded     with       acute 

hepatitis 608 

with  typhoid  fever 608 

with  yellow  fever 608 


982 


INDEX. 


Liver,  cancer  of G14,  620,  G30 

chronic  atrophy  of. 539 

congestion  of. 610,  623 

confountled  with  cancer  of 

■    liver 623 

witli  chronic  gastritis  611 

with      hvpertrophv      of 

liver...". : Gil 

with  torpt>r  of  liver 611 

nervous  syraj)toms  in 611 

intlamniation  of. 612 

cirihosis  of 633 

hypertrophic 635 

decrease  in  size  of 633 

diseases  of. 636 

dropsy  in 632 

jaundice  in 632 

malarial  infection  in 636 

pain  in 632 

displacement     of,    from     tight 

lacing 610 

enlargement     of,     confounded 

with  chronic  pleurisy 370 

fatty 618,  623 

confounded    with    cancer  of 

liver 623 

fibro-fattv.  636 

hydatids  of 614,  628,  636 

hypertrophy  of 611 

movable 656 

percussion  of. 485 

pigment,       confounded      with 

acute  hepatitis 600 

pyajmic  abscess  of. 618 

red  atrophy  of 637 

simple  induration  of 637 

symptoms  in  diseases  of. 592 

syphilitic,      confounded     with 

cancer  of  liver 624 

table  of  diseases  of. 597 

torpor  of 611 

tropical  abscess  of 599,  618 

waxy 619,  623 

confounded   with   cancer    of 

liver 623 

diseases  confounded  with 620 

Locomotor  ataxia 142 

arthropathies  of,    distinguished 

from  rheumatic  arthritis...  816 
differs  from  general  paralysis...   145 

of  syphilitic  origin 147 

similar  to  hysteria 146 

Lumbago 810 

Lumbar  region,  tumors  of. 656 

Lungs,     acute    affections    of,    in 

typhoid  fever 838 

confounded   with   tubercular 

meningitis 168 

cirrhosis  of 374 

collapse  of. 311,  312,  375 


Lungs,  diseases  of 258,  288 

tistulous  opening  into 375 

hydatids  of 370 

inllammation  of 893 

a>dema  of 346,  723 

scrofulous  disease  of 336 

symptoms  of  diseases  of. 289 

syphilitic  disease  of 330 

confniuuled  witii  jihlhisis 330 

Lung-tissue,  detection  of 314 

Lupus 919 

Lyinphadenoma 786 

distinguished   from    lymphatic 

cancer 787 

Lymphatic  glands,  cancer  of 657 

sarcoma  of 787 

Lymphomas,  local  gland 787 

distinguished   from    Hodgkin's 

disease 787 


M. 

Macuhe 919 

Malaria,  poisoning  by 876 

Malarial  cachexia 869 

lux'maturia 875 

Malformations  of  heart 435 

confounded  with  valvular  af- 
fections   435 

Malignant  pustule 946 

Mania,  acute 171 

alcoholic 173 

confounded  with  acute  men- 
ingitis    172 

with  delirium  tremens 172 

urasmic ^ 725 

Measles 891 

catarrh  in 892 

complications  of. 893 

confounded      with      miliarv 

fever "..  894 

with  scarlet  fever 890 

with  smallpox 892 

with  typhus  fever 892 

eruption  in 892 

German  876 

malignant,     confounded     with 

cerebro-spinal  fever 852 

Meliena  582 

Melancholia,  acute 173 

Melasma 919 

Memory,  disordered 58 

Meniere's  disease 74,  86,  612 

Meningitis,  acute 159 

confounded  with  acute  mania  172 

with  acute  softening 161 

with  apoplexy  ., 178 

with  cerebritis 161 


INDEX. 


98?» 


Meningitis,     acute,     confounded 

with  delirium  tremens...   170 
witli      head-symptoms     of 

acute  rheumatism 163 

of  acute  ulcerative  endo- 
carditis     164 

of  continued  fevers 161 

of  pericarditis 164 

of  pneumonia 164 

with  typhoid  fever 887 

cerebro-spinal 169 

confounded  with  myelitis 117 

diseases  confounded  with 850 

chronic,  distinguished  from  tu- 
mor    214 

of  the  base  of  the  brain 160 

of  the  convexity  of  the  brain...   160 

ordinary  165 

spinal 116 

tubercular 164 

diseases  confounded  witli 850 

distinguislied  from  acute  hy- 
drocephalus     166 

from  cerebro-spinal  fever...  851 
from  chronic  liydrocephalus  166 

from  hysteria  168 

from    inflammatory    affec- 
tions of  the  lungs 168 

from  typhoid  fever 167 

Mensuration  of  chest -259 

Mental  faculties,  diseases  charac- 
terized by  gradual  impair- 
ment of 209 

Mercurial  tremor 941 

Metritis   confounded    with    acute 

cystitis 743 

with  peritonitis 549 

Migraine 71 

Miliaria  papulosa 911 

Milk-leg  confounded  with  acute 

rlieumatism 805 

Milk-sickness 947 

Mind-blindness 86 

Molluscum  926 

Monoplegia  106 

brachial  107 

brachio-facial  107 

crural  108 

facial 107 

facio-lingual  108 

oculo-motor  108 

Morphoea 923 

Motion,  deranged 90 

voluntary,  diseases  marked  by 

sudden  loss  of. 173 

Mouth,  diseases  of 462 

gangrene  of 464 

inflammation  of. 462,  464 

morbid  appearances  of 461 

Multiple  neuritis 113,  146 


Multiple  neuritis  contrasted  with 

acute  ascending  paralysis...  115 
contrasted  with  acute  myelitis..  115 

Mumjis 474 

Murmur,  respiratory  274 

vesicular 272 

ab.sence  of. 275 

causes  of 272 

changes  in 273 

Murmurs,  cardiac 387 

endocardial 387,  408 

from  lung-changes 437 

functional  valvular 436 

hsemic 391 

in  the  course  of  fevers 410 

musical... 438 

pericardial  392 

without  valvular  lesion 436 

Musete  volitantes  76 

Muscle,  rectus,  contraction  of. 652 

Muscles,   appearance   of,   in    pa- 
ralysis       94 

morbid  states  of,  paralysis  from..     92 
Muscular   contraction,    paradoxi- 
cal      90 

movements,  irregular  forms  of..   146 

sense 69 

diminution  or  loss  of 146 

Myalgia 224,  811 

Myelitis  117 

acute,  contrasted  with  acute  as- 

cendiiig  paralysis  115 

contrasted  with  multiple  neu- 
ritis    115 

central 119 

disseminated  119 

from  compression 118 

hemorrhagic  119 

transverse 119 

Myocarditis 423 

acute 423 

chronic 424 

Myostatic  contraction 88 

Mvxojdema 762,  922 


N. 


Narcolepsy     distinguished    from 

trance 184 

Narcotics,  insensibility  from 180 

poisoning  by 932 

Nasal  catarrh 306 

Nausea  as  a  symptom 495 

Nematoda 951 

Nephralgia 713 

confounded  with  colic 536 

Nephritis  712 

acute,   confounded   with   acute 

Briffht's  disease 721 


984 


I>'DEX. 


Nephriti*,  acute,  confounded  with 

acute  cystitis 743 

bacillosa  intei-stitialis  priuiaria..  720 

chronic  consecutive 733 

distinguished  from  Briglit's 

disease 733 

intei-stitial  738 

suppurative  721 

Nepliroplithisis 733 

Nerves,  diseases  of 52 

paralysis  from  ati'ections  of 91 

Nervous    affections,    cUissification 

of. 158 

deranged    nutrition   and    se- 
cretion in 154 

centres,  diseases  of,  anaesthesia 

a  symptom  of. 65 

paralysis  from  90 

system,  diseases  of. 52 

Neuralgia   223 

abdt)minal  539 

as  a  cause  of  headache 71 

cerebral 227 

confounded  with  aneurism 662 

with  loeal  inflammation 223 

with  pain  of  rheumatism.. 223,  809 

epileptiform 226 

facial 225 

distinguished    from     painful 

anaesthesia  of  fifth  nerve...  225 
distinguished  from  spasm  of 

face 226 

in  Bright's  disease 729 

intercostal 359,  399 

confounded  with  acute  pleu- 
risy   359 

lumbo-abdominal 539 

of  bladder 537 

of   spinal    nerves     confounded 

with  colic 539 

of  stomach 539 

ovarian 538 

reflex 224 

Neurasthenia 212 

associated  with  neuralgia 224 

Neuritis,  acute  progressive 113 

optic 83 

Night  palsy 767 

terrors 59 

Nutrition,  deranged 154 

O. 

CEdema 758 

of  the  glottis 240 

diagnosticated  from  croup....  241 

pulmonary 346,  723 

mistaken  for  pneumonia 346 

occurring  in  Bright's  disease  723 


(Esophagus,  dilatation  of 478 

inflammation  of. 477 

strieture  of 477 

spasmodic 478 

Omentum,  cancer  of 627 

Ophthalmoscope  in  diseases  of  the 

nervous  system 71,  82 

Opisthotonus 204 

Opium  poisoning 933,  938 

Optic  nerve,  atrophy  of 83 

neuritis ! 83,  217 

tract,  diseases  of  the 104 

Orthopncea  :>0,  290 

Ovarian  cysts 631 

dropsy  confoundi  d  with  ascites  641 

inflannnation 538,  561 

neuralgia 539 

tumors  657 

0.\alate  of  lime  in  the  urine.. .686,  713 

O.xaluria 686 

Oxvuris  vermicularis 951 


P. 

Pachymeningitis  spinalis  interna.  117 

Pain  as  a  symptom 43 

abdominal,  in  typhoid 829 

cardiac 396 

gastric,  as  a  symptom 502 

in  diseases  of  the  liver 592 

in  laryngeal  aft'ections 231 

paroxysmal,  diseases  character- 
ized by 223 

Palpation  of  the  chest 262 

Palpitation 400 

cardiac,  diseases  attended  with.  401 
Palsv.     See  Pai^alysis. 

Bell's :..  128 

cerebral 139 

facial,  double 129 

functional 91 

limited 123 

local 128 

shaking 149,  220 

wasting 133 

Pancreas,  diseases  of. 651 

Pancreatitis,  acute 548 

confounded  with  peritonitis..  548 

chronic 651 

Papillitis..  83,  217 

Papular  diseases 911 

Parsesthesia 64 

Paralysis 90 

acute  anterior  spinal 138 

ascending 112 

contrasted  with  acute  myelitis  115 

with  multiple  neuritis 115 

agitans 148,  220,  816 

distinguished   from  chorea...  198 


INDEX. 


985 


Paralysis     agitans    distinguished 

■    from  general  paralysis...  220 

from  rheumatism 816 

associated  with  gangrene 92 

bulbar 135 

by  compression 130 

clinical  investigations  of. 94 

cross 100 

diphtheritic 126,  146 

electro-muscular      contractility 

in 96 

sensibility  in 98 

essential 137 

facial 128 

from  affection  of  nerves  at  their 

extremities 91 

from  apoplexy. 178 

from  chronic  softening 209 

from  interference  with  the  cir- 
culation      92 

from  lead  poisoning i....92,  125 

from  lesion  of  nervous  centres..     91 
from  lesion  in  the  course  of  a 

nerve 91 

from  locomotor  ataxia 148 

from  morbid  state  of  the  mus- 
cles      92 

from  poisoning 92 

from       progressive      muscular 

atrophy 133 

from  reflex  action 91 

functional 91 

general 90,  218 

distinguished  from  other  pal- 
sies   219 

glosso-labio-lary  ngeal 131 

glosso-laryngeal 135 

glosso-pharyngeal 135 

glossoplegic 108 

hysterical. 91,  123 

infantile 137 

Intermitting 92 

■     local 128,  134 

malarial 92 

of  nerves  of  the  arm 130 

of  vocal  apparatus 291 

partial 90 

peripheral 91 

pseudo-hypertrophic  muscular..  137 

radial 130 

reflex , 92 

rheumatic 125 

spastic  spinal 121 

sudden,  distinguished  from  apo- 
plexy     Ill 

syphilitic 126 

from  inherited  taint 128 

tabular  view  of. 140,  141 

with  muscular  wasting 132 

Paraplegia 110 


Paraplegia,  ataxic 145 

cervical 118 

from  spinal  hemorrhage Ill 

from  various  diseases 112 

gradual 115 

reflex 122 

seat  of  lesion  in 110 

spastic 146 

spinal Ill 

sudden Ill 

Parasites 949 

animal 950 

fly 956 

vegetable 949 

Paresis 90 

spinal 112 

Parotitis 474 

See  also  Mumps. 

Patellar  tendon  reflex 89 

Pectoriloquy 284 

Pelvic  cellulitis  658 

Pemphigus 915 

foliaceus 915 

syphilitic 915 

Percussion 263 

auscultatory 266 

clearness  of,  as  a  diagnostic  sign.  301 
dulness   of,   diseases    accompa- 
nied by 313,  338,  424 

mediate 263 

of  abdominal  viscera 484 

of  healthy  chest 268 

respiratory 267 

sounds  elicited  by 264 

Perforation,  intestinal,  confound- 
ed with  colic 534 

Periarteritis  nodosa 763,  966 

Pericardial  eftusion 434 

mistaken    for     dilatation    of 

heart 434 

murmurs 392 

Pericarditis,  acute 414 

diagnosticated     from    endocar- 
ditis    418 

from  gastric  irritation 420 

from  inflammation  of  brain..  420 

from  pleuritis 418 

friction  sounds  of. 415 

head-symptoms  of,  confounded 

with  meningitis 164 

in  Bright's  disease 724 

indurated  mediastino- 422 

Pericardium,  dropsy  of 419,  434 

eftusion    of,    confounded    with 

chronic  pleurisy 371 

Perihepatitis 599 

confounded  with  acute  hepatitis  599 

Perinephritis 746 

distinguished    from    inflamma- 
tion of  psoas  muscle 747 


986 


INDEX. 


Periostitis 22G 

Perituneum,  abscess  of 059 

carc'iuouia  of. 059 

colloid  cancer  of 659 

diseases"  of. 527,  645,  659 

hydatid  disease  of 659 

sarcoma  of. 660 

Peritonitis,  acute 543 

associated  with  acute  pancre- 
atitis   548 

confounded  with   abdominal 

hysteria 553 

with  acute  enteritis 548 

with  acute  gastritis 548 

with  colic 540,  554 

with  cystitis 549 

with  distention  of  blad- 
der   549 

with  inflammation  and  ab- 
scess of  abdominal  mus- 
cles    550 

with  metritis 549 

with  rheumatism  o{  ab- 
dominal walls 553 

with  typhoid  fever 837 

chronic 555,  638,  644 

cancerous  deposits  in 556 

confounded  with  ascites 555 

from  collections  of  pus  in  the 

cavity 551 

from  extravasation  into  the  sac.  546 

local  547 

puerperal 546 

tubercular  644 

Perityphlitis 559 

Pernicious  an;vmia 779 

confounded  with  Addison's  dis- 
ease     791 

with  chlorosis 783 

with  contracted  kidney 783 

with  disease  of  heart 783 

with  leukaemia 784 

with  ordinary  anfemia 783 

with     orsj;anic    disease    of 

stomach 782 

with  pseudo-leukaemia 783 

Pettenkofer's  test 691 

Phantom  tumors 653 

Pharyni^eal   fever 906 

Pharyngitis      confounded      with 

'  diphtheria 469 

Phar^'nx  and  oesophagus,  diseases 

of. 462,  476 

Phlebitis 766 

Phlegmasia  alba  dolens..759,  766,  795 
confounded  with  rheumatism...  805 

Phosphates  in  the  urine 680 

Phosphatic  diathesis 682 

Phthisis 313 

acute 338,  348 


Phtiiisis,      acute,      distinguished 

from  meningitis 341 

from  typhoid  fever 341,  838 

bronchial 296 

cavity  from 333 

diHei"S   from    pulmonary    ab- 
scess   334 

chronic  pneumonic 324 

confountled  with  bronchial  dil- 
atation     331 

with  brouLliial  phtiiisis 323 

with  chronic  bronchitis 323 

witii  chronic  pleurisy 328 

with  chronic  pneumonia 324 

with  cm])hy,sema 323 

witii  pulmonary  abscess 332 

with  iiulmonary  cancer 329 

with  puliiKiuary  gangi'ene 334 

with  s\  philitic  disease  of  the 

lungs 330 

cough  in 313 

fibroid 374 

laryngeal 252 

of  old  people 324 

pneumonic 327,  341 

retrogression  of 336 

ternj)erature  in 316 

tubercular,  acute 838 

Physical  diagnosis 256,  258 

Pigment  liver 600 

Pityriasis  rubra 917 

Plague  confounded  with  typhus  ..  846 

Pleura,  cancer  of 369 

effusion  into 371 

fistula  of 375 

friction  sound  in 419 

liquid  in 419 

Pleurisy,  acute 312,  348,  354 

confounded       with        acute 

Bright's  disease 724 

with  acute  pneumonia 357 

with  intercostal  neuralgia..  359 

with  pericarditis 371,  418 

with  pleurodynia 359 

bilious 352 

chronic 328,  365,  372 

confounded   with   abscess   in 

thoracic  walls 371 

with  cancer 369,  373 

with     chronic    pneumonic 

consolidation 373 

with  cirrhosis 374 

with  collapse  of  lung.. 312,  375 

with  emphysema 368 

with  enlargement  of  liver..  370 
with  enlargement  of  spleen  370 

with  hydrothorax 371 

with  intra-thoracic  tumor..  368 
with  pericardial  effusion...  371 
with  phthisis 328 


INDEX. 


987 


Pleurisy,      chronic,     cnnfounded 

witli  pneumotliorax  

with  tubercle 

diseases  confounded  with 

circumscr  1  bed 

diaphragmatic,  confounded  with 

acute  hepatitis 

double 

Pleuritic  efl'usion....310,  355,  616, 

Pleurody n ia  

confounded  with  acute  pleurisy 

Pneumatometry 

Pneumo-hydro-pericardium  

Pneumonia 

acute 

confounded  with  acute  bron- 
chitis  

with  acute  phthisis  

with  acute  pleurisy 

with  bilious  pneumonia 

with  cerebro-spinal  fever... 
with  hypostatic  congestion 
with  pulmonary  apoplexy, 
with  pulmonary  engorge- 
ment in  fevers 

with  pulmonary  oedema.... 

with  typhlitis 

with  typhoid  pneumonia... 
head-symptoms  of,  confound- 
ed with  meningitis 

auscultation  in.  

bilious 

catarrhal 304, 

chronic,        confounded        with 

chronic  pleurisy 324, 

confounded  with  phthisis 

chronic  catarrhal 

lobar 

lobular 311, 

mistaken  for  bronchitis 

for  collapse 

malarial 

physical  signs  of...: 

typhoid  

Pneumothorax 310,  361, 

diagnosticated     from     chronic 

pleurisy 

from  diaphragmatic  hernia... 

from  emphysema 

without  perforation 

Pneumotyphus 

Podelcoma 

Poisoning,  aconite 

acute  

alcohol 934, 

alkaline  

aloes 


ammonium. 


aniline 

antimony. 


368 
373 
368 
369 

602 
329 
630 
359 
359 
262 
422 
342 
342 

348 
348 
357 
352 
852 
346 
347 

346 
346 
562 
350 

164 
343 
352 
349 

373 
324 
327 
312 
349 
348 
312 
352 
343 
350 
422 

365 
364 
363 
364 
844 
949 
937 
928 
939 
929 
932 
929 
935 
931 


Poisoning,  antipyrin 936 

arsenic. 931,  934 

atropine 934 

belladonna 934 

benzene 934 

bisulphide  of  carbon 945 

bromine 930 

brucine 937 

by  poisonous  exhalations 948 

by  ptomaines 948 

Calabar  bean 937 

cantharides  931 

carbolic  acid 935 

charcoal  fumes    935 

cheese,  egg,  milk 931 

chloral  ..^ 933,  939 

chlorine 930 

chloroform 933,  939 

chronic 938 

coal  gas  935 

colchicum 932 

colocynth 932 

conium  935 

copper 930,  943 

corrosive  sublimate 931 

cream  puff. 931 

diazobenzene 931 

digitalis 937 

elaterium 932 

ergot  932,  941 

ether 933,  939 

followed  by  coraa 62 

fungi  932 

hydrochloric  acid 929 

hydrocyanic  acid 935 

hyoscyamus 934 

iodine 930 

iron 930 

irritant 591,  928 

lead 930,  942 

lobelia 932 

malarial 876 

mercurial 931,  941 

muscarine 932 

narcotic 932 

insensibility  from,  confound- 
ed with  apoplexy 933 

nitric  acid 929 

nitrobenzole  181 

nitro-glycerin 936 

opium 933,  938 

oxalic  acid 929 

paraldehyde 940 

petroleum 936 

phosphorus 930,  945 

picrotoxin 938 

potassium  iodide 930 

producing  anaesthesia 65 

headache 72 

paralysis 92 


988 


INDEX. 


Poisoning,  prussic  acid 935 

sausage 'J  3 1 

savin '•o'J 

silver 9o0 

sodium....' 9;!0 

strychnine 9o7 

confounded  with  epilepsy 988 

with  hydrophobia 988 

with  tetanus 207,  938 

sulphuric  acid 929 

tobacco 932,  940 

veratrum  viridc 937 

zinc 930,  945 

Poisons 928 

animal,  diseases  caused  by ..945,  946 

irritant 928 

Poliomyelitis 119,   138 

Polyuria 754 

chronic,  distinguished  from  true 

diabetes 755 

Portal    veins,    inflammation    of, 
confounded      with      acute 

hepatitis 600,  637 

inflammation  of,  with  coagula..  637 

Position  as  a  symptom  30 

Progressive  muscular  atrophy,  183,  138 
distinguished  from  bulbar  pa- 
ralysis    135 

from  cerebral  hemiplegia 134 

from  general  spinal  paralysis  134 

from  idiopathic  atrophy 136 

from  infiuitile  paralysis 138 

from  local  paralysis 134 

from  overuse  of  muscles 135 

from        pseudo-hypertrophic 

muscular  paralysis 137 

from  syringo-myelitis 136 

from    unilateral    atrophy   of 

the  face \ 135 

Prostate  gland,  hemorrhage  from  706 

Prurigo 911 

Pruritus 926 

Pseudo-leukaemia 784 

Pseudo-scarlatina 891 

Pseudo  tabes  mesenterica 493,  654 

Psoriasis 917 

Ptomaines 948 

Ptosis 81 

Puerperal  malarial  fever 862 

Pulsation,  abdominal 661 

aortic 661 

confounded  with  aneurism  of 

abdominal  aorta 663 

Pulse,  condition  of,  in  disease 33 

dicrotic 87 

irregular 34 

respiration-ratio,  perverted 342 

slow  34 

Pulsus  paradoxus 422 

Purging,  diseases  attended  by,  575,  585 


Purpura 802 

acute 808 

distinguished     from     htemo- 

phiiia 808 

luemorrhagicu 802 

rheumatica 802 

Purulent  urine 722 

diseases  associated  with 742 

Pus  in  internal  cavities 861 

in  urine 706 

Pustule,  malignant 946 

Pva^mia 791 

'arterial 793 

chronic  or  relapsing 794 

confounded    with    acute    atiec- 

tions  of  liver  793 

with  acute  glanders 792 

with  intermittent  fever 861 

with  rheumatic  fever 792 

with  typhoid  fever 792 

spontaneous  septico- 798 

Pyelitis 747 

catarrhal 749 

from  irritation  of  calculi 749 

Pj'onephrosis 749 

confounded  with  abscess  of  the 

kidney 750 

with  suppurative  nephritis...  750 
Pyo-pneumothorax,  subphrenic...  616 
Pyrosis 498 


Q. 

Quinoidine,  animal,  in  malaria...  870 
Quinsy  distinguished  from  secon- 
dary parotitis 466 


R. 

Kachitis 221 

Kadial  nerve,  paralysis  of. 180 

Kales ■ .' 279 

Eash,  mulberry 840 

of  scarlet  fever 887 

Raynaud's  disease 767 

Records  of  cases,  plans  for 29 

Reflexes,  aural 88 

cranial  88 

deep 88 

derangements  of. 86 

laryngeal 88 

nasal 88 

patellar  tendon 89 

pharyngeal 88 

reinforcement  of. 89 

superficial 87 

tendo  Achillis 87 


INDEX. 


989 


Eeflex  excitability 87,  99 

abdominal H7 

cremaster 87 

crossed 89 

epigastric 87 

tendon 87 

Regions  of  chest 257 

Relapsing  fever 85-1 

confounded  with    typhoid  and 

typhus  fever 857 

with  yellow  fever 856,  884 

Remittent  fever 863 

distinguished    from  acute  con- 
gestion of  the  liver.... 866 

from    inflammation    of     the 

brain 866 

from  intermittent  fever 865 

from  typhoid  fever 866 

infantile 871 

Renal  artery,  multiple  aneurisms 

of 751 

colic, 713 

concretions,  forms  of. 713 

enlargements 631 

growths 658 

hsematuria 702 

inadequacy 734 

veins,  thrombosis  of 756 

Respiration,  amphoric 230,  279 

bronchial 277 

broncho-cavernous 279 

cavernous 278 

feeble 273 

harsh 276 

in  children,  peculiarities  of 287 

jerking 275 

metallic 279 

metamorphosing  breath-sound..  279 

prolonged 275 

puerile...  273 

sounds  of,  in  health 271,  272 

supplementary 273 

vesiculo-bronchial 276 

vesiculo-cavernous 279 

Respiratory  movements 258 

percussion  263 

Retinal  hemorrhage 83 

Retinitis 83 

albuminuric 83 

anaemic 83 

diabetic 88 

leukaemic 83 

pigmentosa 83 

Retropharyngeal  abscesses...  246,  476 

Rheumatic     fever     distinguished 

from  pyeemia 792 

gout 1 815 

paralysis 125 

Rheumatism 804 

acute 804 


Rheumatism,   acute,    confounded 

with  acute  synovitis 805 

with  cerebro-spinal  fever...  852 

with  milk-leg 805 

with  rickets 819 

with  trichiniasis 964 

head-symptoms       of,       con- 
founded with  meningitis, 

163,  807 

heart-symptoms  in 807 

cerebral 808 

chronic 808 

confounded  with    abdominal 

aneurism 662 

with  neuralgia 223 

with  organic  structural  dis- 
ease    809 

with  paralysis  agitans 816 

with  sciatica 228 

feigned 812 

gonori'hoeal 806 

muscular 809 

confounded  with  trichiniasis, 

811,  964 

of  abdominal  walls 553 

of  cervical  muscles 852 

periosteal 812 

relations  of,  to  chorea 197 

subacute 808 

Rheumatoid  arthritis 816 

Rhinoscopy , 236 

Rhonchi 279 

Rhythm  of   respiration,    changes 

in 275 

Rickets 816 

craniotabes  confounded  with....  819 

diagnosis  of 818 

hereditary  syphilis  confounded 

with 818 

moUities  ■    ossium     confounded 

with 818 

rheumatism  confounded  with...  819 
Rigidity,  local,  confounded  with 

tetanus 206 

Rose-cold 306,  825 

Roseola 910 

Rubella 895 

Rubeola  notha 894 

Rupia 917 


S. 


Salaam  convulsions •...  200 

Salivation  462 

Sarcinse  ventriculi 498 

Scabies 914,  923 

Scalp,  rheumatism  of,  confounded 

with  hemicrania 227 


990 


INDEX. 


Scarlatina.  886 

distinguished  from  cerebro-spi- 

nal  meningitis 851 

from  diphtheria  473 

from  measles S'JO 

from  membranous  croup 8U1 

from  smallpox 890,  900 

from  typhoid  fever 890 

exhaustion  in 890 

sore  throat  of 887 

tongue  in 888 

Sciatica 227 

distinguished  from  hip-joint  af- 
fections   229 

from  irritation  of  the  kidney  229 

from  rheumatism 228 

feigned 229 

pressure  of  fluid  on  nerve  in....  228 

rheumatic 228 

Scleroderma 921 

Sclerosis,  cerebro-spinal 149,  220 

multiple 149 

posterior 142 

Scrofula  and  tubercle 336 

pulmonary 336 

Scrofulous  glands 787 

distinguished  from   lymphade- 

noma 787 

Scurvy 801 

confounded  with  purpura 802 

Seborrhcea 925 

Secretion,  deranged 154 

Sensation,  deranged 63 

impaired 63 

perverted 63 

Sensations  of  patients 43 

Senses,  special,  derangement  of....     75 

Septicaemia 794 

Skin,  condition  of,  as  a  symptom     33 

diseases 907 

bullous 915 

classification  of. 908 

erythematous 909 

from  altered  gland-secretion..  925 

nervous 926 

papular. 911 

parasitic... 923 

pustular 915 

squamous 917 

syphilitic 927 

vesicular 912 

hypertrophies  of. 921 

maculte  of 919 

new  growths  in 919 

Sleep,  "protracted,    distinguished 

from  apoplexj- 183 

Smallpox   896 

confluent 897 

distinguished  from  measles...  900 
from  scarlet  fever 890,  900 


Smallpox  distinguished  from  va- 
rioloid...r. 901 

eruption  in 897 

invasion  of. 897 

Softening  of  the  brain 209 

acute,    confounded    with    acute 

meningitis..  161 

with  apoplexy 182 

chronic ! 209 

discriminated  from  abscess...  211 

from  congestion 210 

from  exhaustion  of 

brain-)io wer 212 

from  tumor 213 

paralysis  from 210 

red 209 

relations  of,  to  hemorrhage...  210 

white ■ 209 

of  spinal  cord 119 

Sore  throat 465 

chronic 474 

chronic  rheumatic 475 

clergyman's 475 

follicular 475 

in  scarlet  fever 887 

Sound,  bronchial 272,  276 

elicited  by  percussion 361 

Ilippocratic,  or  succussion 263 

in  chest,  adventitious 279- 

tubular 272- 

Spasm,  bronchial 292- 

facial 226 

distinguished  from  choi'ea 198 

masticator}-,  of  the  face 206 

of    bladder     confounded     with 

colic 537,  555 

of  glottis  in  croup 242 

Spasmodic  dorsal  tabes 120 

Spasms 152 

See  also  Convulsions. 

clonic 152 

diseases  marked  by 191 

f u nc tion al 208 

saltatory 153 

tonic...". 152 

Spinal  ancemia 116 

cord,  atrophy  of. 119 

congestion  of 115 

gout  of. 814 

hemorrhage  into Ill 

inflammation  of. 116 

distinguished     from     epi- 
demic cerebro-spinal 

meningitis  851 

morbid   conditions    of,    as    a 

cause  of  parapleg  i  a Ill 

sclerosis  of 119 

softening  of 119 

syphilis  of. 122 

tumors  of 121 


INDEX, 


991 


Spinal  cord,  tumors  pressing  on  ...   122 

meningitis 116 

acute 117 

paresis 112 

sclerosis 119 

disseminated  120 

lateral  amyotrophic 121 

primary 120 

of  antero-lateral  columns 119 

Spine,     disease     of,     confounded 

with  aneurism 663 

disease  of,  confounded  witli  c  die.  540 

irritable 116 

Spleen,  affections  of 649 

chronic 649 

displacement  of 655 

enlargement  of.  370 

confounded      with      chronic 

pleurisy 370 

inflammation  of 649 

percussion  of 486 

Sporadic  cerebro-spinal  meningitis  851 

Spotted  fever 840 

Sputa 297 

of  acute  pneumonia 298,  342 

of  bronchitis 297,  305 

of  phthisis 313 

Stethoscope 270,  271 

application   of,    to   larynx  and 

trachea 231 

Stomach,  acidity  of,  as  a  symptom  493 

acute  diseases  of. 508 

inflammation  of 508 

cancer  of  518,  626,  638 

contrasted  with  chronic  gas- 
tritis   521 

contrasted  with  gastric  ulcer.  521 

catarrh  of. 510 

chronic  affections  of 512 

cramp  of 503 

dilatation  of 526 

confounded  with  dilatation  of 

large  intestine 527 

diseases  of. 490 

organic,  confounded  with  per- 
nicious ansemia 782 

examination  of  contents  of 490 

fibroid  thickening  of. 524 

gout  in 814 

hemorrhage  from 500 

inspection  of 482 

irritation  of,  confounded   with 

pericarditis 420 

membrane  of,  secondary  inflam- 
mation of 511 

neuralgia  of 503 

palpation  of. 483 

percussion  of 484,  487 

perfoi'ation     of,     distinguished 

from  irritant  poisoning 929 


Stomach,  softening  of. 511 

ulcer  of. 514 

Stomatitis 468,  470 

mercurial 462 

ulcerative,     confounded     with 

diphtheria 470 

Stools  as  symptoms , 528 

examinations  of 529 

Strabismus  79 

Strangulation,  internal 572 

Stricture  of  the  oesophagus 479 

Stridor,  laryngeal 230 

Strongylus  gigas 956 

Strychnine  poisoning 937 

confounded  with  tetanus,  207,  938 

Stupor 61 

in  urijemia 724 

St.  Vitus's  dance.     See  Chorea. 

Sugar  in  the  urine 691 

tests  for 692 

Sugar  of  milk  694 

Sulphates  in  urine,  pathology  of..  684 

test  for , ". 684 

Sun-stroke 188 

distinguished  from  apoplexy....  188 
Supi-a-renal  capsules,  disease  of...  787 

Surface  thermometry 46 

Sweat-glands 926 

Sweating,  excessive.  156 

Sycosis 925 

Symptoms,  disguised 25 

febrile,  in  typhoid 826 

feigned 23 

pathognomonic 21 

similarity  of,  in  diseases 25 

study  of , 26 

Syncope  distinguished  from  apo- 
plexy    182 

Synovitis,      acute,       confounded 

with  acute  rheumatism 805 

Syphilis    combined    with    lar3'u- 

gitis 248 

Syphilitic   diseases  of  the  brain, 

126,  214,  862 

of  the  liver 620 

of  the  lungs...  330 

of  the  skin 927 

of  the  spinal  cord 122 

fever    confounded    with    inter- 
mittent fever 862 

ulcers  of  fauces 476 

Syringo-myelitis 136 


T. 

Tabes  dorsalis 142 

See  Locomotor  Ataxia. 

mesenterica 654 

pseudo  mesenterica 493,  654 


992 


INDEX. 


Tactile  l^ense,  inipainni'iit  of 09 

Tfenia  lata i'o-i 

mediocanellata 'Ju4 

sol i uii) 952 

Tape-wonii  ul'  pork 952 

Teinpt'i-atuiv  of  liody  as  a  symp- 
tom       -14 

tvrcl.ral 4i;,  lUIl 

in  apoplexy 174 

in  cancer 51 

in  ccreljro-spiual  lever 849 

in  intermittent  fever ..    859 

in  measles 891 

in  phthisis 316,  338 

in  pyiemia 791 

in  relapsing  fever 854 

in  rcmittenl  fever 8G4 

in  scarlatina 887 

in  smallpox 898 

in  trichiniasis 9G1 

in  typhoid  fever 827 

in  typhus  fever 841 

of  surface 4() 

Tenderness 44 

Tendon  reflex 88 

Tetanus 204 

confounded  with  hydrophobia..  207 

with  local  rigidity 20G 

with  muscular  rheumatism...  206 
with  spasms  in  scarlet  fever..  205 
with    strychnine    poisoning, 

207,  938 
distinguished      from      cerebro- 
spinal fever 205,  851 

from  chorea 198 

hysterical 205 

idiopathic 204 

intermittent 206 

symptomatic 205 

traumatic 204 

Thermometer,  clinical  use  of 44,  51 

See  also  Temperature. 

Thei-mometry,  cerebral 109 

general 47 

surface 40 

Thirst  as  a  symptom 493 

Thomsen's  disease 208 

Thoracic  aneurism 450 

confounded  with  abscess  of  the 

mediastinum 452 

with  chronic  laryngitis 457 

with  dilated  auricle 454 

with  insufficient  aortic  valves  453 
with    intra-thoracic    morbid 

growth 451 

with    malformation    of    the 

chest 456 

with  malposition  of  the  aorta  456 

with  morbid  growths 451 

with  pulsating  empyema 454 


Thoracic     aneurism     confovuidi'd 
with   pulsation  of  jmlmo- 

nary  artery 455 

eructations  in 495 

Thrombosis 750,  795,  800 

from  chlorosis 790 

from  exhausting  diseases 790 

t)f  brain  sinuses 215,  795 

of  cerebral  arteries 179 

of  renal  vein 756 

Thrush 403 

Tic  douloureux 63 

Tinea 923 

circinata 925 

favosa 724 

sycosis 925 

tonsurans 925 

versicolor 925 

Tinnitus  auriuni 86 

Tobacco  amblyopia 84 

Tongue,  cancer  of. 405 

condition  of,  in  disease 40 

inilamiuation  of. i.  464 

syphilis  of. , 465 

Tonsillitis 466 

confounded  with  diphtheria 409 

Torticollis 811 

Trachea,  affections  of 230,  254 

morbid  growths  in 254 

narrowing  of 254 

symptoms  of  diseases  of 231 

ulcers  in 254 

Trance   distinguished    from    nar- 
colepsy   184 

Tremor 148 

alcoholic 150 

arsenical 151 

convulsive 199 

essential 151 

functional 150 

hereditary 151 

in  spasmodic  tabes 150 

lead 151 

mercurial 151 

post-hemiplegic 150 

senile 150 

tobacco 151 

Trial  meal 490 

Trichina  spiralis 957 

Trichiniasis 811,  9G0 

distinguished  from  Bright's  dis- 
ease   966 

from  cardiac  disease 966 

from  cholera  morbus 965 

from  irritant  poisoning 965 

from  periarteritis  nodosa 966 

from  rheumatism 811,  964 

from  sausage  poisoning 965 

from  typhoid  fever 962 

from  typhus  fever 963 


INDEX. 


m 


Trichiniasis,  oedema  in 903 

pulmonary  symptoms  in 904 

Trichoccphalus  dispar 952 

Trismus.... 204 

Tube-casts  in  the  urine 7o7,  738 

Tubercle  317,  325,  329 

and  scrofula 386 

calcareous  transformation  of. 336 

confounded  with  chronic  pleu- 
risy   329 

Tubercular  meningitis 164 

Tuberculosis  of  lungs 325 

See  also  Phthisis. 

acute  miliary ,...339,  341 

combined  with  laryngitis  252 

confounded  with  Bright's  dis- 
ease    732 

Tumors,  abdominal 648 

confounded  with  colic 540 

aneurismal 292,  309 

cerebral 213 

distinguished  from  apoplexj-.   178 
from  chronic  meningitis...  214 

from  softening 214 

natureof 217 

seat  of 215 

in  hypochondrium,  left 649 

in  hypochondrium,  right 648 

intra-thoracic,  confounded  with  368 

chronic  pleurisy 368 

mediastinal 452 

non-aneurismal,        confounded 

with  abdominal  aneurism..  663 

of  epigastrium 651 

of  iliac  region 657 

of  larynx 253 

of  lumbar  region 656 

of  spinal  cord 121 

of  spleen 649 

of  umbilical  region 654 

ovarian 657 

phantom 653 

Tympanitis,   chronic 647 

confounded  with  ascites 646 

Typhhtis 558 

confounded  with  pneumonia....  562 
Typhoid    conditions    confounded 

with  typhoid  fever 835 

Typhoid  fever,  abortive , 839 

confounded  with  cerebi'o-spinal 

fever 850 

with  enteritis 836 

with  general  debility. 835 

with  meningitis 167,  837 

with  peritonitis 837 

with  pulmonary  affections...  838 

with  pyajmia 792 

with  remittent  fever 866 

with  scarlet  fever 890 

with  trichiniasis 962 


Typhoid   fever   confounded  with 

typhoid  conditions 835 

with  typhus  fever 844 

with  ui(!crative  endocarditis..  837 

with  yellow  fever 884 

convulsions  in 831 

delirium  in 831 

diarrhoea  in 829 

enlai'gement  of  the  spleen  in...  829 

epistaxis  in 832 

eruption  in 832 

mild 839 

nervous  symptoms  in 831 

palsy 832 

relapses  in 833 

spinal  symptoms  in 831 

urine  in , 827 

walking 835 

Typho-malarial  fever 877 

Typhus  fever 839,  896 

acute  tubercular  deposits  in 844 

and  typhoid  fever  compared 845 

cerebral  symptoms  in 841 

complications  in 844 

confounded  with  measles 892 

with  plague 846 

with  yellow  fever 884 

distinguished  from  acute  men- 
ingitis    842 

froin  cerebro-spinal  fever 852 

eruption  in 840 

maculated 840 

physiognomy  of 840 

pulse  in 743 

temperature  in 841 

urine  in 843 

Tyrosine 688 

U. 

Ulcer  of  duodenum,  corrosive 517 

gastric 514 

confounded  with  chronic  gas- 
tritis   521 

with  gastric  cancer 521 

with  ulcer  of  duodenum ...  517 

peptic 518 

perforating,  of  the  foot 950 

Umbilical  region,  tumors  of 654 

Uraamia 724,  933 

convulsions  in 725 

delirium  in 725 

distinguished      from      cerebro- 
spinal fever 852 

mania  in 725 

Ursemic  coma  distinguished  from 

apoplexy , 181 

Urates,  pathology  of. 678 

tests  for 679 


63 


994 


TXDEX. 


Urea,  patht>lo£jy  of C<1'^ 

tabU' for  estiinatioii  of (ITti 

test<  for '. '174 

Urethrn,  honiorrhiim'  from 70(1 

Urethral    li.'vor    confouiulcd  with 

intcrinitti'iit  fever ^i\\ 

Uric  aeid  in  gout 818 

detection  of. 818 

pathology  of. 675 

Urinary  organs,  diseases  of.. ..6(55,  712 

Urine 605 

abnonnal  constituents  of 686 

acetone  in 694 

acid,  free,  in 671 

iilhuniinous   c()ndition    of,    ilis- 

eases  marked  by 718 

alkaline 672 

analysis  of. 667 

bile  in 689 

bloody 699 

calcium  oxalate  in 686 

ca.<ts,  mucous,  in 737 

changes  in  constituents  of 673 

chlorides  in 683 

chylous 709 

color  of,  changes  in 668 

estimate  of  solids  in 670 

fat  in 708 

lil)rin  in 709 

increased  discharge  of. 751 

ingredients  of. 667 

inosite  in 694 

kreatin  and  kreatinin  in  685 

leucine  in 688 

pigment  in 669 

lihosphates  in 680 

alkaline 680 

earthv 680 

testfi.r 682 

purulent,      confounded      with 

acute  Bright's  disease 722 

diseases  associated  with 742 

pus  in 706 

quantitative  examination  of 666 

r ea  c  t  i  o  n 671 

retention  of. 757 

sediments 709 

specific  gravity  of 669 

sugar  in 691 

suly)hates  in 684 

sup])ression  of. 756 

table   showing   action    of    tests 

vipon 710 

tyrosine  in 688 

Urobilin 669 

1 1 roei-y  th  ri n 669 

Uroha!matoi)orphvi'in  669 

Urticaria .' 910 

Uterus,  colic  of 538 

gravid,  eiinfuiindi'il  with  nscites  646 


V. 

Vagrants'  disease 790 

\'alvular  att'ections  of  tlie  heart...  435 
confounded  with  functional  car- 
diac tli><.)rder 436 

with  malformations  of  heart.  435 
with  misdirection  of  current.  436 
diagnosis    of,    before    dev<dop- 

ment  of  murmur 448 

from  rupture  of  a  valvulet 448 

table  of. 435 

Varicella 901 

Variola 896 

Varioloid 901 

Veins,  portal,  intlammation  of....  600 

thrombosis  of 795 

I'enal 756 

Vertigo 72 

aural 74 

cerebral 73 

essential 75 

from  overwork ■  75 

laryngeal 75 

jirccursor  of  epilepsy 75 

stomachal 73 

Vesicular  murmur,  absence  of 275 

changes  in 273 

Viscera,     abdominal     percussion 

and  auscultation  of. 484 

Vision,  derangement  of. 75 

Vocal  cord,  diseases  of 250 

fremitus,  absence  of 285 

resonance 284 

Voice,  altered 248 

amphoric 285 

auscultation  of. 284 

cavernous 284 

changes  in,  in  larvngeal  diseases  230 

metallic .'...■.' 284 

whispering 284 

Vomit,  black 881 

coftee-ground 501 ,  520 

different  forms  of ,.  497 

Vomiting  as  a  symptom 495 

diseases  accompanied  bv....  508,  585 

t;ecal '. 499 

gastri  c 517 

in  brain  diseases 517 

nervous 497 

of  bile 499 

of  blood 501 

W. 

Water-brash  498 

WeiPs  disease 603 

Womb,     inllamniiition    nf,    con- 

foiuided  with  piiritimitis....   546 
Wool-sorters'  disease 946 


INDEX. 


995 


Word-dcafncss 187 

Worms,  intestinal 951 

Wrist  clonui? 90 

Writer's  crump 200 

Wry-neck 811 

X. 

Xanthine 714 

Y. 

Yellow  fever 876,  880 

confounded  with  Asiatic  chol- 
era   884 


Yellow    fever    confounded     witli 

plague 883 

with  relapsing  fever 884 

with  remittent  fever 870,  885 

with  typhoid  fever 884 

with  typhus  fever 884 

walking 882 


Zinc  poisoning 945 


THE    END. 


Printed  by  J.  B.  Lippincott  Company,  Philadelphia, 


FROM 

J.  B.  LIPPINCOTT  COMPANY'S 

tologue  of  Medical  and  ^ui^gieal  Woi^I^^. 


THOMAS'S  MEDICAL  DICTIONARY.  A  Complete 
Pronouncing  Medical  Dictionary.  Embracing  the  Terminology 
of  Medicine  and  the  kindred  Sciences,  with  their  Signification, 
Etymology,  and  Pronunciation.  With  an  Appendix,  comprising 
an  Explanation  of  the  Latin  Terms  and  Phrases  Occurring  in 
Medicine,  Anatomy,  Pharmacy,  etc. ;  together  with  the  Necessary 
Directions  for  Writing  Latin  Prescriptions,  etc.,  etc.  By  JOSEPH 
THOMAS,  M.D.,  LL.D.,  Author  of  the  System  of  Pronunciation 
in  Lippincott's  "  Pronouncing  Gazetteer  of  the  World,"  and  "  Pro- 
nouncing Dictionary  of  Biography  and  Mythology."  On  the  basis 
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The  aim  in  the  preparation  of  this  work  has  been  not  only  to  embrace  within  a  convenient 
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tioner or  medical  student  should  be  familiar,  but  also  to  combine  therewith  much  other  inform 
mation  not  usually  found  in  similar  works,  but  yet  necessary  to  a  perfect  dictionary  for  the 
profession.  Thus,  coupled  with  the  definitions  of  the  terms,  are  given,  whenever  practicable, 
the  I.,atin  and  Greek  words  from  which  the  terms  are  derived,  by  this  means  adding  greatly 
to  the  clearness  of  the  definitions.  Another  marked  peculiarity  of  the  volume  is  the  pronun- 
ciation of  the  terms,  a  feature  hitherto  unaltempted  in  any  work  of  the  kind  (except  in  a 
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it  greatly  in  advance  of  anything  of  the  kind  we  that  he  has  succeeded  in  presenting  a  medical 

have  had  for  a  number  of  years.     In  fact,  a  dictionary  which,  for  the  daily  use  of  the  stu- 

need  existed  for  just  such  a  book,  and  I  will  dent  or  the  practitioner,  is  superior  to  any  other 

certainly  recommend  it  to  my  class  as  the  best  in  the  language." — Canada  Medical  Record. 
of  its  kind.     Its  unquestioned  merits  will  soon  "  No  better  testimonial  to  the  value  of  the 

supplant  all  others."— Pro/.  J.  A.  McCORKLE,  work  can  be  given  than  the  following  from  Dr. 

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every   physician.      This   dictionarv   supplies   a  ^'^^   ™°^^!"   ^^^d^^nce   01   medical   science   has 

place  that  has  never  been  filled.     I  have  looked  introduced.     Of  course  I  cannot  conceive  the 

It  through  and  find  all  the  new  words  that  I  have  learning  and  great  labor  which  could  edit  such 

soughtr-Prof.  A.  F.  Patton,  College  of  Phy-  a  complete    thorough    and  admirable  volume 

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f    -^ 


AN  ELEMENTARY  TREATISE  ON  HUMAN  ANAT- 
OMY. By  JOSEPH  LEIDY,  M.D,  Professor  of  Anatomy  in 
the  University  of  Pennsylvania,  etc.,  etc. 

New  (second)  edition,  rewritten  and  enlarged.     Containintr  495  illustrations. 
8vo.     Extra  cloth,  $6.00;  sheep,  ^6.50. 


In  the  preparation  of  this  great 
work,  Dr.  Leidy  has  given  special 
attention  to  those  parts  of  the 
human  body,  a  minute  knowledge 
of  which  is  essential  to  the  suc- 
cessful practitioner  of  surgery  and 
medicine.  The  names  in  most 
text-books  are  given  in  Latin;  the 
author,  however,  has  as  far  as  pos- 
sible used  an  English  equivalent 
for  such  names,  the  Latin  being 
given  in  foot-notes.  Various  other 
improvements,  such  as  long  ex- 
perience has  suggested,  have  also 
been  made  in  the  nomenclature 
of  the  science.  The  illustrations 
are  numerous  and  largely  original, 
and  prepared  in  the  best  style  of 
the  engraver's  art.  As  most  of 
the  recent  text-books  of  anatomy 
are  very  cumbersome,  the  conden.- 
sation  of  this  volume  is  a  feature 
of  great  merit.  The  first  edition 
of  the  work,  which  has  been  out 
of  print  for  many  years,  was  very 
highly  esteemed,  and  old  copies 
have  long  commanded  extravagant 
prices.  The  present  edition  (en- 
tirely rewritten)  presents  the  ripe 
fruits  of  Dr.  Leidy's  experience 
of  many  years  of  successful  labor 
as  a  teacher  and  as  an  original  ob- 
server and  discoverer  in  anatomical 
science,  and  the  work  will  be 
everywhere  recognized  as  the  lead- 
ing authority  on  the  subjects  of 
which  it  treats. 


TESTIMONIALS. 
"  I  am  well  pleased  with  the  simple  manner  "After  a  thorough  inspection  I  am  pleased 
in  which  the  complex  subject  is  handled.  I  to  pronounce  Leidy's  Aiiato/ny  a  most  excel- 
very  much  like,  too,  the  way  in  which  the  sclen-  lent  work.  It  covers  the  entire  field  in  a  mas- 
tific  names  of  parts,  etc.,  are  used,  as  in  most  terly  manner,  and  deals  with  subjects  entirely 
of  our  anatomical  text-books  this  has  proved  a  overlooked  by  other  authors.  It  will  afford 
source  of  much  trouble  and  discouragement  to  me  much  pleasure  to  introduce  it  not  only 
those  beginning  to  study.  I  shall  recommend  in  my  school,  but  to  recommend  it  to  the 
the  book  to  my  classes." — W.  E.  Bloyer,  profession  in  general."  —  S.  F.  Carpenter, 
M.D.,  Professor  of  Anatomy,  Eclectic  Medical  Northwest  Medical  College,  St.  Joseph,  Mo. 
Institute,  Cincinnati,  Ohio. 


J.  B.  IJppiucott  Company  s  Medical  and  Surgical  Works. 

A   SYSTEM    OF   ORAL    SURGERY.      Being   a   Treatise 

on  the  Diseases  and  Surgery  of  the  Mouth,  Jaws,  Face,  Teeth, 
and  Associate  Parts.  By  JAMES  K.  GARRETSON,  A.M., 
M.D.,  p.D.S,  President  of  the  Medico-Chirurgical  Hospital,  and 
Emeritus  Professor  of  Oral  and  General  Clinical  Surgery  in  the 
Medico-Chirurgical  College ;  Dean  o^  the  Philadelphia  Dental 
College,  etc. 

Illustialed  witli  steel  plates  aiul  numerous  wood-cuts.     Fifth  Edition,  tlioroughly 
revised,  with  important  additions.     8vo.     Cloth,  ^9.00;  sheep,  ^10.00. 


The  interim  between  the  present 
and  the  immediately  preceding  edi- 
tion of  this  book  has  been  a  con- 
tinuation of  work  by  its  author  with 
view  to  enlarging  and  elaborating 
experiences  that  might  prove  of 
benefit  to  his  patients,  his  students, 
and  himself.  An  observer,  in  look- 
ing over  the  volume  in  hand,  and 
comparing  it,  even  with  the  last  of 
former  issues,  will  find  continued  in- 
crease in  the  way  of  new  chapters, 
together  with  many  added  illustra- 
tions, while  alterations  and  interpo- 
lations will  meet  his  eye  on  almost 
every  page.      This   new  matter  and 

manner  replaces,  in  no  sense,  the  old,  for  the  writer  happily  is  without  occasion  to  change 

any  opinion  or    judgment   that    has   been   advanced.     The   meaning  of   the   additions   lies 

with  the  rapid  growth  and  advance  of  the  specialty.     As  to  change  of  manner  to  be  seen, 

this  is  with  view  to  a  still  further  con- 
densation of  the  matter  of  the  book 

and  to  such   elaboration  in  way  of 

presentation  of  the   subjects   treated 

in  it  as  shall    make   them   easier  of 

comprehension  by  a  student,  and,  if 

possible,  more  practical. 

Oral   surgery,   twenty  years   back, 

was   without    so    much    as    a    name. 

To-day,  oral  surgery,  as  a  specialty  in 

medicine,  is  not   surpassed  as  to  its 

range  and  as  to  requirements  looked 

for  on  the  part  of  its  practitioners,  by 

any  department  of   the    healing    art. 

It  has  become  what  it  is  by  reason  of 

the  need  for  its  existence. 

As  expounded  in  the  present  work, 

and  as  the  specially  might  not  othei- 

wise  have  existence,  oral  surgery  in- 
cludes dentistry;    it  includes  it  in  a 

)iurely  surgical  sense,  thus  assuming 

dentistry  to   be    not  a  profession  in 

itself,  but  part  of  medicine  at  large  ; 

such  assumption  being  founded  on  an 

experience  which  clearly  enough  ex- 
hibits that  where  medical  knowledge 

is  lacking  dentistry  is  of   very  little 

use  to  a  community. 

What  oral  surgery  is,  and  what  dentistry  is  when  practised  from  the  stand-point  of  oral 

surgery,  it  is  left  to  the  volume  to  show. 


J.  B.  Lippincott  Company's  Medical  and  Snrgical  Wuvkr. 


THE   PRACTICE   OF   PHARMACY.     A  Treatise  on  the 

Modes  of  Making  and  Dispensing  Officinal,  Unofficinal,  and  Ex- 
temporaneous Preparations,  with  Descriptions  of  their  Properties, 
Uses,  and  Doses,  Intended  as  a  Hand-Book  for  Pharmacists  and 
Physicians  and  a  Text-Book  for  Students.  Second  Edition.  En- 
larged and  Thoroughly  Revised.  By  JOSEPH  P.  REMINGTON, 
Ph.M.,  F.C.S.,  Professor  of  Theory  and  Practice  of  Pharmacy  and 
Director  of  the  Pharmaceutical  Laboratory  in  the  Philadelphia 
College  of  Pharmacy,  etc. 

Containing  over  1300  pages  and  630  illustrations.     8vo.     Cloth,  extra,  $6.00;  sheep,  ^6.50. 

The  vnlue  of  the 
method  of  proving 
progress  in  knowl- 
edge by  answering 
questions  has  been 
recognized  in  this 
edition,  and  a  series 
of  questions  on  ihe 
subjects  embraced 
has  been  appended 
to  each  chapter. 

After  the  chapter 
on  Metrology,  typi- 
cal pharmaceutical 
problems  and  exer- 
cises in  alligation 
have  been  inserted. 
Part  v.,  treating  of 
Magistral  Phar- 
macy, and  Part  VI., 
containing  the 
Formulary  of  Un- 
officinal Prepara- 
tions, have  been 
revised  and  greatly 
extended.  More 
than  one  hundred 
illustrations  and  fifty 
pages  have  been 
added  to  Part  V.  Fac-similes  of  one  hundred  autograph  and  questionable  prescriptions, 
selected  to  demonstrate  how  various  difficulties  occurring  in  daily  practice  may  be  overcome, 
and  accompanied  by  running  comments,  constitute  the  most  important  addition  to  this  portion 
of  the  work.  These  have  been  printed  upon  enamelled  paper  with  special  care,  in  order 
that  the  originals  may  be  faithfully  reproduced.  By  the  incorporation  of  the  National  For- 
mulary, the  elision  of  those  formulas  which  might  conflict  with  this  authority,  and  the  addition 
of  others,  it  is  believed  that  greater  usefulness  in  this  Part  will  be  secured.  The  additions 
represent  a  net  increase  of  two  hundred  pages,  the  illustrations  numbering  six  hundred  and 
thirty-nine,  or  one  hundred  and  forty  more  than  were  in  the  first  edition.  A  very  complete 
and  useful  index  has  been  added. 

TESTIMONIALS. 


Remington's  Percolating  Stand. 


"  I  do  not  hesitate  to  say  it  is  the  most 
complete  book  on  Pharmacy  that  can  be  had. 
By  the  excellent  arrangement  the  editor  has 
adopted  at  the  end  of  each  chapter,  students 
can  avail  themselves  of  a  self-examination 
which  can  only  result  to  their  good,  and  give 
them  a  belter  understanding  of  Pharmacy  in 
all  its  branches.  I  can  conscientiously  say 
that  no  druggist  or  druggist's  clerk  should  be 


without  a  copy." — Edivard  W.  Runyoii, 
Dean  of  the  Faculty,  College  of  Pharmacy, 
San  Francisco,  Cal. 

"  It  is  not  too  much  to  say  that  '  Reming- 
ton's Practice'  is  the  greatest  and  most  com- 
prehensive exponent  of  the  science  and  the 
art  from  the  time  of  Paracelsus  to  the  present 
day." — Western  Druggist,  Chicago,  III. 


J.  7).  Lippi)icott  Company  s  Medical  and  Surgical  Works. 


THE    PRINCIPLES   AND    PRACTICE    OF   SURGERY. 

Being   a  Treatise    on    Surgical    Diseases    and    Injuries.      By    D. 

HAYES  AGNEW,    M.D.,  LL.D.,  Professor  of  Surgery   in    the 

Medical  .Department  of  the  University  of  Pennsylvania. 

Revised    Edition    of  1S90.     Three    volumes.     8vo.     Price   per  volume:    Extra 
cloth,  ;S7.5o;  sheep,  $8.50;   half  Russia,  $9.00. 

VOLUME  I.  embracing 
Surgical  Diagnosis,  Inflam- 
mation, Wounds,  Injuries  of 
the  Head,  Injuries  of  the 
Chest  and  Abdomen,  Wounds 
of  the  Extremities,  Diseases 
of  the  Abdomen,  Diseases 
and  Injuries  of  the  Blood- 
Vessels,  Ligation  of  Arteries, 
Surgical  Dressings,  Injuries 
and  Diseases  of  tlie  Osseous 
System. 

VOLUME  XL  contains 
1070  pages,  with  791  illus- 
trations, embracing  Disloca- 
tions, Diseases  of  the  Joints, 
Excision  of  Joints  and  Bones, 
Consideration  of  Subjects 
connected  with  Minor  Sur- 
gery, on  the  use  of  the  Knife, 
Venesections,  General  Considerations  with  regard  to  Operations,  Anresthelics,  Amputation, 
Shock,  Traumatic  Fever,  Furunculus,  Phlegmon  or  Boil,  Injuries  and  Diseases  of  the 
Genito-Urinary  Organs,  Surgical  Diseases  of  Women,  Surgical  Affections  of  the  Spinal  or 
Dorsal  Region,  Malformation  of  the  Head  from  Effusion,  Surgical  Diseases  of  the  Alouth. 

VOLUME  IIL  contains  900  pages,  with  475  illustrations,  embracing  Surgical  Dis- 
eases of  the  Larynx  and  Trachea,  Diseases  and  Injuries  of  the  Nose,  the  Naso-Pharyngeal 
Region  and  the  Associate  Parts,  Diseases  and  Injuries  of  the  Eye  and  its  Appendages,  Dis- 
eases and  Injuries  of  the  Ear,  Malformations  and  Deformities,  Tenotomy  in  the  Treatment 
of  Orthopjedia,  Affections  of  the  Muscles,  Tendons,  Bursa;,  and  Aponeuroses,  Surgical 
Affections  of  the  Nerves,  Surgical  Affections  of  the  Lymphatic  System,  Skin,  and  Sub- 
cutaneous Connective  Tissue,  Syphilis,  Tumors,  Diseases  of  the  Mammary  Glands,  Electro- 
Therapeutics  as  applied  to  Surgery,  Massage. 

PRESS   COMMENTS. 

"  It  is  wonderful,  and  yet  it  is  never  verbose,      It  embodies  the  Ion 


but  always  concise  ;  never  rambling,  but  always 
practical.  The  matter  is  good, — all  good, — and 
the  complete  work  will  be  not  only  a  monument 
of  personal  patience  and  literary  effort,  but,  all 
things  considered,  the  best  standard  text-book 
on  surgery  in  the  English  language." — New 
York  Afedical  youriial. 

"This  great  work  bears  a  favorable  com- 
parison with  the  most  famous  systems  of  sur- 
gery that  have  been  issued  by  a  wonderfully 
prolific  press  that  has  been  literally  and  con- 
stantly fed  by  the  best  writers  of  any  age  on 
any  subject  pertaining  to  our  art.  As  we  turn 
the  leaves  of  the  three  great  volumes  we  feel  a 
personal  glow  of  pride  in  that  they  are  fitting 
representatives  of  the  labors  of  an  American 
surgeon.  The  cuts  and  the  printing  deserve 
special  mention  for  their  excellence." — Cincin- 
nati Lancet- Clinic. 

"The  second  edition  of  this  excellent  text- 
hook  on  surgery  has  just  made  its  appearance. 


valuable  experience  of  one 
of  the  most  distinguished  surgeons  and  teachers 
of  surgery  in  America.  Unlike  many  of  our 
text-books,  it  is  not  a  mere  compilation  of  the 
views  and  observations  of  others,  but  every 
page  bears  the  imprint  of  one  who  is  not  only 
a  careful  and  wise  observer  himself,  but  a  com- 
petent and  impartial  critic  of  the  work  of  others." 
— New  York  Intenialional  Jotiryial  of  Surgery, 

"The  style  of  this  treatise  is  admirably 
simple,  clear,  and  concise, — qualities  which  are 
often,  in  technical  books,  conspicuous  by  their 
absence.  None  need  ever  read  a  sentence  a 
second  time  in  order  to  understand  its  meaning 
or  to  perceive  its  connection  with  what  precedes 
or  follows.  .  .  .  The  whole  field  of  surgery  is 
surveyed  by  a  master  mind.  Each  chapter  is 
pregnant  with  wisdom,  and  the  physician  who 
daily  turns  the  pages  of  '  .Agnew's  Surgery'  need 
have  no  fear  of  ever  wandering  far  astray  from 
the  safe  path  of  treatment." — Philadelphia 
Medical  Bulletin. 


/.  B.  Lippincott  Company's  Medical  and  Surgical  Works. 


THERAPEUTICS:  Irs  Principles  and  Practice.  A  work 
on  Medical  Agencies,  Drugs,  and  Poisons,  with  Especial  Reference 
to  the  Relations  between  Physiology  and  Clinical  Medicine.  By 
H.  C.  WOOD,  M.D.,  LL.D.,  Professor  of  Materia  Medica  and 
Therapeutics,  and  Clinical  Professor  of  Diseases  of  the  Nervous 
System  in  the  University  of  Pennsylvania. 
Seventh  edition,  revised,  rewritten,  and  enlarged.     8vo.     Cloth,  ^6.00;  sheep, 


'.50- 


Although  this  work  has  been  thor- 
oughly revised  from  time  to  time,  on 
no  previous  occasion  have  the  changes 
been  so  great  as  in  the  present  edition. 
What  in  the  last  edition  was  the  sec- 
ond portion  of  the  book  has  been  made 
into  part  first,  and  has  been  so  enlarged 
as  to  take  into  consideration  not  only 
the  application  of  forces  for  the  relief  ->, 
of  human  ailment,  but  also  the  sub- 
jects of  diet,  massage,  metallo-therapy,  fi 
and  the  special  treatment  of  constitu- 
tional conditions.  8 

9 

That  portion   of    the   book   which 

treats  of  drugs  has  also  been  rear-  10 
ranged  in  accordance  with  an  entirely  j 
new    classification.      All    the    articles     ^* 

la 

upon  the  older  members  of  the  materia     ir 

.  17 

medica  have  been  thoroughly  revised,     is 

and,  whenever   possible,  made  more     jt, 

complete,  accurate,  and  practical ;  the 

accounts  of  all  the  more  recent  drugs 

have  been  entirely  rewritten,  whilst  a 

large  number  of  new  drugs  have  been 

discussed.     The  additions  to  the  book 

amount  to  about  two  hundred  pages. 


[bPECI   ir       ILL      TrATION  ] 


PRESS   COMMENTS. 


"  This  book  should  be  in  the  hands  of  all  who 
wish  a  safe  and  reliable  treatise  on  the  subject  of 
therapeutics." — Southern,  Clinic,  Richmond,  Va. 

"  Although  always  a  favorite  for  the  concise- 
ness of  the  text  and  the  reliability  of  therapeutic 
teaching,  in  its  new  dress  it  has  excelled  itself, 
and  is  likely  to  hold  its  own  against  all  rivals." 
—  Wilmington  {N.C.)  Medical  yoiwnal. 

"We  doubt  if  any  work  published  on  the 
subject  of  Therapeutics  has  proved  as  popular 
on  this  continent  as  this.  We  have  for  years 
had  a  very  high  opinion  of  Wood's  '  Therapeu- 
tics,' and  we  are  pleased  to  notice  in  the  pres- 
ent volume  that  the  distinguished  author  is 
keeping  fully  up  to  the  times.  We  can  recom- 
mend this  book  with  great  confidence,  as  being 
a  safe  and  reliable  guide  to  the  senior  medical 
student  and  the  general  practitioner," — Practi- 
tioner, Toronto,  Canada. 


"  As  a  work  of  reference  it  will  form  a  most 
valuable  addition  to  the  library  of  every  mem- 
ber of  the  medical  profession." — Edinburgh 
Medical  yournal. 

"Taken  all  in  all,  we  have  little  hesitation 
in  pronouncing  this  the  most  reliable  work  on 
therapeutics  in  the  English  language." — Phila. 
Medical  Times. 

"  As  a  whole,  for  both  practitioner  and  stu- 
dent, it  is  in  our  judgment  the  best  work  in  the 
English  language  upon  the  subject  of  which  it 
treats." — The  Sanitarian. 

"  It  is  a  work  of  condensed  matter  and 
onerous  labors,  without  a  single  line  of  useless 
verbiage  or  tautological  sentence,  bringing  be- 
fore the  examiner's  mind  the  pith  and  fulness  of 
the  old  professional  acumen,  and  brought  up  to 
the  times  by  most  modern  additions." — St.  Louis 
Medical  yournal. 


J.  B.  Lippi)icott  Company s  JMcdical  and  S/i/xhd/  Iloj-Z^'s. 

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Atlee   (Washing:ton  1.,   M.I).).      Diagnosis  of 

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Burnett  (Charles  H.,  M.  D.).  Diseases  and  In- 
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Chavasse  (P.  H.,  M.D.).  Advice  to  a  Wife,  and 
Advice  and  Counsel  to  a  Mother.     3  vols. 

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trated.    Svo 3  00 

Davies   (Nathaniel   E.).      Foods   for    the   Fat. 

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Garretson  (J.  E,).     A  System  of  Oral  Surgery. 

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Hand-Book  of  Nursing- (A).     i2mo 1.25 

Heath  (Christopher,  F.R.C.S.).     A  Dictionary 

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Hopkins  (William  Barton,  M.D.).     The  Roller 

Bandage.     With  Illustrations.     i2mo     .    .    .    1.25 
Jaksch   (Dr.  Rudolph  von).     A  Text-Book  of 

Clinical  Diagnosis.     Svo 6.50 

Jaraipson  (W.  Allen,  M.D,,  F.P.C.,  P.E.).  Dis- 
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Keating  f  John  M.,  M.D.).    Maternity  ;  Infancy  ; 

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leuckart  (R.).     Parasites  of  Man.     Svo.    .    .    .    6.50 
Maclaren  (P.  H.,  M.D.).     Atlas  of  Venereal  Dis- 
eases.    10  parts.     Royal  410.     Per  part    .    .    2.00 
Mills  (Chas,  K.).     The  Nursing  and  Care  of  the 

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Mitchell  (S,  W,,  M.D,),     Injuries  of  the  Nerves. 

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Packard   (John   H.,  M,D.).     A    Hand-Book   of 

Operative  Surgery.     Svo 5.00 

Sheep 5.7s 

Rand.     Elements  of  Medical  Chemistry.     i2nio    2.00 

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Remington  (J.  P.).  Practice  of  Pharmacy.   New 

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Riley  (John  C,  A,M,  M,D,).     Materia  Medica. 

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